For Dates of Service Before March 1, 2010

Services in the Nursing Home Daily Rate

Covered nursing home services are medically necessary services provided by a certified nursing home to a nursing home member and prescribed by a physician in a POC.

Services in the Daily Rate

According to DHS 107.09, Wis. Admin. Code, routine nursing home services and costs, reimbursed in a nursing home's daily rate, include the following:

• Nursing services.
• Special care services, including activities, therapies, recreation, social services, and religious services.
• Supportive services, including dietary, housekeeping, maintenance, and institutional and personal laundry services (excluding personal dry cleaning services).
• Administrative and other indirect services.
• Physical plant, including depreciation, insurance, and interest on plant.
• Property taxes.
• OTC analgesics and medically necessary noncovered OTC drugs.
• Non-medical transportation services. (Medical transportation is separately reimbursable, as described in the Nursing Home Rate Administrative Review Request.)
• Services for members with developmental disabilities.
• Supplies and equipment, including dietary supplies, incontinence supplies, personal comfort supplies, medical supplies, medical equipment that is not custom-made, and other similar items. All of these items are associated with a member's personal living needs in normal and routine nursing home operations. Section 5.000 of the Methods of Implementation contains a list of these items.

Ancillary Add-ons to the Nursing Home Daily Rate

Certain services that are normally billed separately from the nursing home daily rate may be included as an ancillary add-on to the nursing home daily rate. An add-on is for specifically identified covered services and materials which could be billed separately by an independent provider of service. These services and materials must be available to all residents of the facility who are enrolled in Medicaid or BadgerCare Plus. If some portion of the services and materials must be supplied by an outside provider, the facility is responsible for payment to the outside provider.

Nursing homes need prior approval for ancillary add-ons. Nursing homes must be able to document that the ancillary add-on will cost no more than if they are billed separately, according to DHS 107.09(4)(1), Wis. Admin. Code. Nursing homes interested in ancillary add-ons should contact their Medicaid regional auditor.

Ancillary Services Reimbursable Beyond the Daily Rate

Ancillary services for nursing home residents are those which are considered non-routine and, as a result, are not included in the nursing home daily rate. Certain covered ancillary services are separately reimbursable from the nursing home daily rate. The costs incurred for ancillary services are billed through revenue codes.

Prior approval is required for all ancillary services except medical transportation. Laboratory and X-ray services require prior approval from the DLTC Nursing Home Section Regional Auditors. For ventilator care, AIDS care, and private room requests, PA is required.

Nursing home providers do not need seication to provide ancillary services. In some cases, nursing homes may need to perform additional services to qualify for Medicaid ancillary coverage.

The allowable ancillary services and their corresponding revenue codes are as follows:

• Transportation services - non-emergency, revenue code 0960. This ancillary service is for medical transportation to obtain health treatment or care. The treatment or care must be prescribed by a physician as medically necessary and must be preformed at a physician's office, clinic, or other recognized medical treatment center. The nursing home must provide the transportation in its controlled equipment and by its staff, or by common carrier (e.g., bus, taxi). The charges are cost per mile, not staff cost. Billings may not exceed the nursing home's actual cost. Routine transportation to activities, such as social events, is part of the daily rate. Medicaid-certified SMV providers may also provide transportation services if certain conditions are met.
• Laboratory services, revenue code 0300.
• Radiology services, revenue code 0320.
• Private room rate, revenue code 0110. A private room may be prior authorized under certain medically necessary conditions for isolation per DHS 132 and CDC guidelines. The DLTC Medicaid Audit Section has more information on qualifying conditions.
• Ventilator/AIDS/ARC services, revenue code 0946. Wisconsin Medicaid provides additional reimbursement for ventilator dependent members admitted to nursing homes authorized to provide ventilator dependent care. The current ventilator rate is listed in the Nursing Home Methods of Implementation in Section 4.690.
• AIDS/ARC services, revenue code 0940. A provider accepting members with a diagnosis of AIDS or ARC may receive additional reimbursement for the member. The current AIDS/ARC rate are listed in the Nursing Home Methods of Implementation in Section 4.690.

Services for Head Injury Patients

A treatment program for head injury patients must be approved by the DLTC based on established criteria for admission, continuing stay, discharge and other program requirements a determined by the DLTC.

Treatment program and rates must be appropriate and receive prior approval from the DLTC Medicaid Audit Section and the Nursing Home Section. Facilities interested in the program requirements and information for treatment of head injured persons should contact:

Director
Division of Long Term Care
P.O. Box 309
Madison, WI 53701-0309