DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services CIs 601 East 12" Street, Suite 235 Kansas City, Missouri 64106 CENTERS for MEDICARE & MEDICAID SERVICES

Division of Medicaid and Children's Health Operations October 20, 2009

Kerry Winterer

Chief Executive Officer

Department of Health & Human Services 301 Centennial Mall South, 3 Floor P.O. Box 95026

Lincoln, NE 68509-5026

Dear Mr. Winterer:

The Centers for Medicare and Medicaid Services (CMS) has completed its review of Nebraska State Plan Amendment (SPA) 09-06 which increases the income limit to 200% FPL for the eligibility group of optional targeted low income children eligible under 1902(a)(10)(A)(ii)(XIV) and 1905(u)(2)(B). This eligibility group serves as the Medicaid expansion group for Nebraska’s CHIP program and this amendment coincides with the Nebraska CHIP amendment #3.

Based on revisions received, we are pleased to inform you that SPA 09-06 is approved with an effective date of September 1, 2009. Enclosed is a copy of the CMS 179 form as well as the approved pages for incorporation into the Nebraska State plan. If you have any questions regarding this amendment, please call Barbara Cotterman at (816) 426-5925.

Sincerely,

ssociate Regional Administrator for Medicaid and Children’s Health Operations

cc: _ Vivianne Chaumont Jon Sterns Pat Taft

Attachment 2.2 -A Page 23b

STATE PLAN UNDER TITLE XIiX OF THE SOCIAL SECURITY ACT State/Territory: Nebraska

COVERAGE AND CONDITIONS OF ELIGIBILITY

Citation(s) Groups Covered

c. are not covered under a group health plan or other group health insurance (as such terms are defined in 2791 of the Public Health Service Act coverage) other than under a health insurance program in operation before July 1, 1997 offered by a State which receives no Federal funds for the program.

d. have family income at or below:

200% of the Federal poverty level for the size family involved, as revised annually in the Federai Register; or

A percentage of the Federal poverty level, which is in excess of the “Medicaid applicable income level” (as defined in 2110(b)(4) of the Act) but by no more than 50 percentage points.

The State covers:

XJ All children described above who are under 19 with family income at or below 200 percent of the Federal poverty level.

(J The following reasonable classifications of children described above who are under age __ with family income at or below the percent of the Federal poverty level specified for the classification.

1902(e)(12) & 21. Achild under age 19 who has been initially determined

of the Act eligible is deemed to be eligible for a total of 6 months regardless of changes in circumstances other than attainment of the maximum age state above.

TN No. 09-06 Supersedes Approval Date*2T 2 ¢ 2009 Effective Date SEP O01 2009

TN No. MS-02-09

DEPARTMENT OF HEALTH AND HUMAN SERVICES, HEALTH CARE FINANCING ADMINISTRATION

FORM APPROVED OMB NO. 0938-0193

TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL

FOR: HEALTH CARE FINANCING ADMINISTRATION

2. STATE Nebraska

1. TRANSMITTAL NUMBER: 09-06

3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID)

TO: REGIONAL ADMINISTRATOR HEALTH CARE FINANCING ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES

4. PROPOSED EFFECTIVE DATE September 1, 2009

5. TYPE OF PLAN MATERIAL (Check One):

([] NEW STATE PLAN

(] AMENDMENT TO BE CONSIDERED AS NEW PLAN

(] AMENDMENT

COMPLETE BLOCKS 6 THRU 10 IF THIS IS ANAMENDMENT (Separate Transmittal for each amendment)

6, FEDERAL STATUTE/REGULATION CITATION: 1902(a)(10)(A)(ii)CXTV) and 1905(u)(2)(B)

7, FEDERAL BUDGET IMPACT: a. FFY 2009 $0 b, FFY 2010 $ 6,088,747 (Title XXI Medicaid Expansion)

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

Attachment 2.2-A, page 23b

9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable):

Attachment 2.2-A, page 23b

10, SUBJECT OF AMENDMENT:

Increasing income limit for optional targeted low income children to 200% FPL

11, GOVERNOR’S REVIEW (Check One): ((] GOVERNOR'S OFFICE REPORTED NO COMMENT [-] COMMENTS OF GOVERNOR’S OFFICE ENCLOSED

(1) NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

(J OTHER, AS SPECIFIED: Governor has waived review

12. see Nae Deceoce F STATE ee Nd Ube y

13. TYPED NAME: Vivianne M. Chaumont

14. TITLE: Director, Division of Medicaid and Long-Term Care

{5. DATE SUBMITTED:

16, RETURN TO:

Patricia (Pat) Taft

Division of Medicaid & Long-Term Care Nebraska Department of Health & Human Services 301 Centennial Mall South

Lincoln, NE 68509

FORM HCFA-179 (07-92)

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services CIS

601 East 12" Street, Suite 235

Kansas City, Missouri 64106 CENTERS for MEDICARE & wencuo sences Division of Medicaid and Children's Health Operations June 17, 2011

Vivianne Chaumont, Director Department of Health & Human Services Division of Medicaid and Long Term Care 301 Centennial Mall S., 5th Floor

PO Box 95026

Lincoln, Nebraska 68509

Dear Ms. Chaumont:

On September 16, 2009, the Centers for Medicare & Medicaid Services (CMS) received Nebraska's State Plan Amendment (SPA) transmittal #09-08, which proposes to implement an average of 1.5% increase in the fee schedule for a number of services.

This SPA 09-008 was approved on June 16, 2011 with an effective date of July 1, 2009 as requested by the State. However, during the review of SPA 09-008, CMS performed an analysis of the coverage and reimbursement provisions that correspond to the impacted services. This analysis revealed issues that will require additional information and/or possible revision through a corrective action plan. Under separate cover, CMS will release a letter detailing those issues, and providing guidance on timeframes for correction. Enclosed is a copy of the CMS-179 form, as well as, the approved pages for incorporation into the Nebraska State plan. ;

If you have any questions regarding this amendment, please contact Narinder Singh at (816) 426-5925 or Narinder.Singh@cms.hhs.gov.

Associate Regional Administrator for Medicaid and Children’s Health Operations

Enclosure

cc: Pat Taft

ATTACHMENT 4.19-B Item 1

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State Nebraska

Except as otherwise noted in the plan, state developed fee schedule rates are the same for both government and private providers and the fee schedule and any annual/periodic adjustments to the fee schedule are published at http://www.dhhs.ne.gov/med/provhome.htm (Division of Medicaid and Long-Term Care website). The above mentioned fee schedule is applicable to all services reimbursed via a fee schedule. The agency’s rates were set as of July 1, 2009 and are effective for services on or after that date.

TN No. NE-09-08

Supersedes ; Approval Date Tune Ih Qoll Effective Date July 1, 2004

Transmittal No. 08-09

Revised s]zo/ 1

DEPARTMENT OF HEALTH AND HUMAN SERVICES | + FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION OMB NO. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF 1. TRANSMITTAL NUMBER: 2. STATE STATE PLAN MATERIAL NE-09-08 Nebraska FOR: HEALTH CARE FINANCING ADMINISTRATION 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) TO: REGIONAL ADMINISTRATOR 4. PROPOSED EFFECTIVE DATE HEALTH CARE FINANCING ADMINISTRATION 07-01-2009

_____ DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One):

(J NEW STATE PLAN (J AMENDMENT TO BE CONSIDERED AS NEW PLAN AMENDMENT . COMPLETE BLOCKS 6 THRU 10 [IF ‘THIS 18 AN AMENDMENT (Separate Transmittal for cach amendment) 6. FEDERAL STATUTEREGULATION CITATION: DERAL BUDGET IMPACT: .FFY 2009 $ 957,499, b. FFY 2010 $3,830,000 & PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: — | 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (if Applicable):

Atiachment 4.19-B Item | Attachment 4.19-B Item 1

10. SUBJECT OF AMENDMENT: Fee Schedule Rates

11. GOVERNOR’S REVIEW (Check One):

((] GOVERNOR'S OFFICE REPORTED NO COMMENT & OTHER, AS SPECIFIED: [-] COMMENTS OF GOVERNOR’S OFFICE ENCLOSED Gavernor has waived review

CJ NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

(2. a) Ve STATE AGENGY OPACIAL: 16. RETURN TO:

Patricia (Pat) Tati

13, yep we seam ont Division of Medicaid & Long-Term Care Se Nebraska Department of Health & Human Services 14. TITLE: : . Director, Division of Medicaid and Long-Term Care 301 Centennial Mall South re 2 LIVIS edicaid and Long- Ler ri Lincoln, NE 68509

18. DATE SUBMITTED: September 16, 2009

FOR REGIONAL OFFICE USE ONLY 18. DATE APPROVED:

17. DATE RECEIVED: Seplenber _}b,9009 Sune |b, Qo! PLAN APPROVED ~ ONE COPY ATTACHED -—\ 19. EFFECTIVE DATE OF APPROVED MATERIAL: 20. SIG URFQERES

31. TYPED NAME:

23. REMARKS:

23. MITLE: Associ Pesipnal Administrator ‘ft ‘Wed, is aN Children's Health DperactionS

FORM HCFA-179 (07-92)

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services

601 East 12" Street, Suite 235

Kansas City, Missouri 64106

Division of Medicaid and Children's Health Operations

CMTS

CENTERS for MEDICARE & MEDICAID SERVICES

March 18, 2010

Kerry Winterer

Chief Executive Officer

Department of Health & Human Services 301 Centennial Mall South, 3% Floor P.O. Box 95026

Lincoln, NE 68509-5026

Dear Mr. Winterer:

The Centers for Medicare & Medicaid Services (CMS) has completed its review of Nebraska State Plan Amendment (SPA) 10-01 which revises cost-sharing provision which apply premiums to certain children eligible under Nebraska’s Autism Home and

Community Based Services Waiver.

Based on the revisions received, we are pleased to inform you that SPA 10-01 is approved with the requested effective date of January 1, 2010. However, the premiums will not be imposed until the Autism waiver is actually implemented.

Enclosed is a copy of the CMS 179 form as well as the approved pages for incorporation into the Nebraska State plan. If you have any questions regarding this

amendment, please call Barbara Cotterman at (816) 426-5925.

Ociate Regional Administrator

Sine

for Medicaid and Children’s Health Operations

cc: Vivianne Chaumont Sally Hinds Pat Taft

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services

7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, Maryland 21244-1850

Center for Medicaid, CHIP, and Survey & Certification

(CENTERS for MEDICARE & MEDICAID SERVICES

Vivianne M. Chaumont, Director

Division of Medicaid & Long-Term Care Department of Health and Human Services 301 Centennial Mall South

Lincoln, Nebraska 68509

RE: NE 10-012

Dear Ms. Chaumont:

AUG 1 8 2010

We have reviewed the proposed amendment to Attachment 4.19-A of your Medicaid State plan

submitted under transmittal number (TN) 10-012.

This amendment revises the payment

methodology for inpatient hospital services, extending a .5 percent rate increase to providers that

was set to expire on June 30, 2010.

We conducted our review of your submittal according to the statutory requirements at sections 1902(a)(2), 1902(a)(13), 1902(a)(30), 1903(a) and 1923 of the Social Security Act and the implementing Federal regulations at 42 CFR 447 Subpart C. We are pleased to inform you that Medicaid State plan amendment 09-010 is approved effective July 1, 2010. We are enclosing the

HCFA-179 and the amended plan pages.

If you have any questions, please call Tim Weidler at (816) 426-6429.

Sincerely,

Put eer

‘Oy eindy Mann

Director, CMCS

Enclosures

ATTACHMENT 4.19-A Page 5

10-010.03Bib___Calculation of Nebraska Peer Group Base Payment Amounts: Peer Group Base Payment Amounts are used to calculate

payments for discharges with a stable DRG. Peer Group Base Payment Amounts effective October 1, 2009 are calculated for Peer Group 1, 2 and 3 hospitals based on the Peer Group Base Payment Amounts effective during SFY 2007, adjusted for budget neutrality, calculated as follows:

1. Peer Group 1 Base Payment Amounts, Excluding Children's Hospitals: Multiply the SFY 2007 Peer Group 1 Base Payment Amount of $3,844.00 by the Stable DRG budget neutrality factor.

2. Children's Hospital Peer Group 1 Base Payment Amounts, Excluding Children's Hospitals: Multiply the SFY 2007 Children's Hospital Peer Group 1 Base Payment Amount of $4,614.00 by the Stable DRG budget neutrality factor.

3. Peer Group 2 Base Payment Amounts: Multiply the SFY 2007 Peer Group 2 Base Payment Amount of $3,733.00 by the Stable DRG budget neutrality factor.

4. Peer Group 3 Base Payment Amounts: Multiply the SFY 2007 Peer Group 3 Base Payment Amount of $3,535.00 by the Stable DRG budget neutrality factor.

SFY 2007 Nebraska Peer Group Base Payment Amounts are described in 471 NAC 10-010.03B4 in effect on September 1, 2007 and 471 NAC 10-010.03B in effect on July 1, 2001.

Peer Group Base Payment Amounts will be increased by 0.5% for the rate period beginning October 1, 2009 and ending June 30, 2010. This rate increase will not be carried forward in subsequent years. Peer Group Base Payment Amounts excluding the 0.5% increase for the rate period beginning October 1, 2009 and ending June 30, 2010, will be increased by .5% for the rate period beginning July 1, 2010.

Transmittal # NE 10-12

Supersedes

AUG 1 8 2019 JUL - 1 2010

Approved Effective

Transmittal # NE 09-02

ATTACHMENT 4.19-A Page 8

June 30, 2009, will be increased by .5% for the rate period beginning July 1, 2010.

10-010.03B3b_Calculation of Stable DI i lu (IME) Cost Payments: Hospitals qualify for IME payments when they receive a direct medical education payment from NMAP, and qualify for indirect medical education payments from Medicare. Recognition of indirect medical education costs incurred by hospitals are an add- on calculated by multiplying an IME factor by the operating cost payment amount.

The IME factor is the Medicare inpatient prospective payment system operating IME factor effective October 1 of the year preceding the beginning of the Nebraska rate year. The operating IME factor shall be determined using data extracted from the CMS PPS Inpatient Pricer Program. For rates effective October 1, 2009, the Department will determine the operating IME factors effective for the Medicare system on October 1, 2008 using the following formula:

{1+(Number of Intems and Residents/Available Beds)}0-405.1] + 1.35

On July 1* of each year, the Department will adopt the Medicare inpatient prospective payment system operating IME factor formulas and rate components in effect on October 1* of the previous year.

10-010.03XXx_ Calculation of MCO Medical Education Payments:

NMAP will calculate annual MCO Direct Medical Education payments and MCO Indirect Medical Education payments for services provided by NMMCP capitated plans from discharge data provided by the hospital.

1.MCO Direct Medical Education payments will be equal to the number of MCO discharges times the MCO direct medical education payment per discharge.

a. The MCO direct medical education payment per discharge is the hospital-specific weighted average fee-for-service DME payment rates for stable DRGs, unstable or low volume DRGs and transplant DRGs, as described in 10- 010.03B3a, 10-010.03B5b and 10-010.03B6b. The weighted average amount shall be based on the claims included in the Fiscal Simulation Analysis as described in 10-010.03B7a.

b. On July 1* of each year, the Department will update the Direct Medical Education payment rates. The Direct Medical Education rates will be increased or decreased based on the annual percentage change in the number of intern and resident FTEs

Transmittal # NE 10-12

Supersedes

AUG 1 8 2010 JUL - 1 2010

Approved Effective

Transmittal # NE 09-10

ATTACHMENT 4.19-A Page 16

10-010.03D1 For payment of inpatient hospital psychiatric services, effective July 1, 2010, the tiered per diem rates will be:

Days of Service Per Diem Rate Days 1 and 2 $691.10 Days 3 and 4 $638.84 Days 5 and 6 $609.81

Days 7 and greater $580.77

-010.03D2__ Payment for Hospital nsored_ Residential Treatment Center Services: Payments for hospital sponsored residential treatment center services are made on a prospective per diem basis. Beginning July 1, 2001, this rate will be determined by the Department and will be based on historical and future reasonable and necessary cost of providing the service. Specific costs to be included in the rate will not be inconsistent with those identified in 471 NAC 32-001.12.

10-01 E Pi ints for ilitati ices: Payments for rehabilitation

discharges are made on a prospective per diem.

All rehabilitation services, regardless of the type of hospital providing the service, will be reimbursed on a per diem basis. This includes services provided at a facility enrolled as a provider for rehabilitation services which is not a licensed rehabilitation hospital or a Medicare-certified distinct part unit. The per diem will be the sum of -

1. The hospital-specific base payment per diem rate; 2. The hospital-specific capital per diem rate; and 3. The hospital's direct medical education per diem rate, if applicable.

Payment for each discharge equals the per diem times the number of approved patient days.

Payment is made for the day of admission but not for the day of discharge.

Transmittal # NE 10-12 WU P L-1 Supersedes Approved AUS 1 8 2010 Effective O10

Transmittal # NE 09-10

ATTACHMENT 4.19-A Page 17

10-010.03E2__Adjustment_of Hospital-Specific Base Payment Amount: The hospital-specific per diem rates will be increased by .5% for the rate

period beginning July 1, 2010.

10.03 Iculation_of Hospital-S) i m : Capitai-related cost payments for the building and fixtures portion of capital-related costs are paid on a per diem as described In 471 NAC 10- 010.03B7 in effect on August 25, 2003.

10.03F_P: nt_for Servi mish Hospital

(CAH): Effective for cost reporting periods beginning July 1, 1999, and after payment for inpatient services of a CAH is the reasonable cost of providing the services, as determined under applicable Medicare principles of reimbursement, except that the following principles do not apply: the lesser of costs or charges (LCC) rule, ceilings on hospital operating costs, and the reasonable compensation equivalent (RCE) limits for physician services to providers.

Transmittal # NE 10-12

Supersedes

roved AUG 1 8 2010 JUL - 1 2010

Effective

App

Transmittal # NE 09-10

OS Notification State/Title/Plan Number: Nebraska 10-012 Type of Action: SPA Approval Required Date for State Notification: 09/15/2010 Fiscal Impact: FFY 10 $657,380 FFY 11 $2,629,528

Number of Services Provided by Enhanced Coverage, Benefits or Retained Enrollment:__ 0

Number of Potential Newly Eligible People: 0 Eligibility Simplification: No

Provider Payment Increase: Yes

Delivery System Innovation: No

Number of People Losing Medicaid Eligibility: 0

Reduces Benefits: No

Detail:

Effective for inpatient hospital services on July 1, 2010 this SPA extends a .5% rate increase that was set to expire on June 30, 2010. Questions surrounding this increase regarding UPL and payment methodology were resolved under the

previous review of this provision (NE 09-010).

Other Considerations:

This plan amendment has not generated significant outside interest and we do not

recommend the Secretary contact the governor.

This OSN has been reviewed in the context of the ARRA and approval of the OSN is

not in violation of ARRA provisions.

CMS Contact: Tim Weidler (816) 426-6429 National Institutional Reimbursement Team

DEPAR’ OF HEALTH AND HUMAN SERVICES FORM APPROVED HEALTH FINANCING ADMINISTRATION OMB NO. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF 1. TRANSMITTAL NUMBER: 2. STATE STATE PLAN MATERIAL 10-12 Nebraska

FOR: HEALTH CARE FINANCING ADMINISTRATION

3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID)

TO: REGIONAL ADMINISTRATOR HEALTH CARE FINANCING ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES

4. PROPOSED EFFECTIVE DATE July 1, 2010

5. TYPE OF PLAN MATERIAL (Check One): (J) NEW STATE PLAN

(2 AMENDMENT TO BE CONSIDERED AS NEW PLAN

AMENDMENT

COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment)

6. FEDERAL STATUTE/REGULATION CITATION:

7. FEDERAL BUDGET IMPACT:

a. FFY 2010 $ 657,380 b. FFY 2011 $2,629,528 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: | 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable): Attachment 4.19-A, p 5, 8,16,17 Attachment 4.19-A, p, 5, 8, 16, 17 10. SUBJECT OF AMENDMENT: Inpatient Hospital Rate Change 11. GOVERNOR'S REVIEW (Check One): (] GOVERNOR’S OFFICE REPORTED NO COMMENT OTHER, AS SPECIFIED: [.] COMMENTS OF GOVERNOR'S OFFICE ENCLOSED Governor has waived review

oO NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

12. SIGNATURE Uy STATE AGENCY OFFICIAL: |

13. TYPED NAME: Vivianne M. Chaumont

14. TITLE: Director, Division of Medicaid and Long-’ Term Care _

15. DATE SUBMITTED:

16. RETURN TO:

Patricia (Pat) Taft

Division of Medicaid & Long-Term Care

Nebraska Department of Health & Human Services 301 Centennial Mall South

| Lincoln, NE 68509

June 16, 2010

FOR REGIONAL, OFFICE USE ONLY

17. DATE RECEIVED:

18. DATE APPROVED: SNe 1d

PLAN APPROVED - ONE COPY ATTACHED

19. EFFECTIVE DATE, OF F APPROVED MATERVAN - 1 2010

SCS 9 am

21. TYPED NAME: \Al

Veen Lasowsic

22. TITLE: "Depury Dice R ,~£ MCS

23. REMARKS:

FORM HCFA-179 (07-92)

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare é& Medicaid Services CAIS 601 East 12% Street, Suite 235

Kansas City, Missouri 64106 CENTERS for MEDICARE & MEDICAID SERVICES

Division of Medicaid and Children's Health Operations October 6, 2011

Vivianne Chaumont, Director Department of Health & Human Services Division of Medicaid and Long Term Care 301 Centennial Mall S., 5th Floor

PO Box 95026

Lincoln, Nebraska 68509

Dear Ms. Chaumont:

On September 29, 2010, the Centers for Medicare & Medicaid Services (CMS) received Nebraska’s State Plan Amendment (SPA) transmittal #10-20, which proposes to implement a .5% increase in the fee schedule for a number of services.

This SPA 10-20 was approved on September 27, 2011 with an effective date of July 1, 2010 as requested by the State. Enclosed is a copy of the CMS-179 form, as well as, the approved pages for incorporation into the Nebraska State plan.

If you have any questions regarding this amendment, please contact Narinder Singh at (816) 426-5925 or Narinder.Singh@cms.hhs.gov.

es G. Scott ‘ociate Regional Administrator for Medicaid and Children’s Health Operations

Enclosure

cc: Pat Taft

ATTACHMENT 4.19-B ltem 14

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State Nebraska

Except as otherwise noted in the plan, state developed fee schedule rates are the same for both government and private providers and the fee schedule and any annual/periodic adjustments to the fee schedule are published at http:/Awww.dhhs.ne.gov/med/provnome.htm (Division of Medicaid and Long-Term Care website). The above mentioned fee schedule is applicable fo all services reimbursed via a fee schedule. The agency’s rates were set as of July 1, 2010 and are

effective for services on or after that date.

TN No. NE-10-20 Supersedes Approval Date Seplenber 3,301 | Effective Date Jul y {, 220/D

Transmittal No, 09-08

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

HEALTH CARE FINANCING ADMINISTRATION OMB NO. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF 1, TRANSMITTAL NUMBER: 2. STATE STATE PLAN MATERIAL 10-20 Nebraska FOR: HEALTH CARE FINANCING ADMINISTRATION 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) TO: REGIONAL ADMINISTRATOR 4, PROPOSED EFFECTIVE DATE HEALTH CARE FINANCING ADMINISTRATION July 1, 2010

DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One):

(] NEW STATE PLAN (0 AMENDMENT TO BE CONSIDERED AS NEW PLAN {] AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment)

6. FEDERAL STATUTE/REGULATION CITATION: 7, FEDERAL BUDGET IMPACT:

a. FFY 2010 $ 271,059

b.FFY 2011 $1,012,669

&. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: | 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (if Applicable):

Attachment 4.19-B, Item | Attachment 4.19-B, Ttem 1

10. SUBJECT OF AMENDMENT: Fee Schedule Rates

tt. GOVERNOR'S REVIEW (Check One):

(7 GOVERNOR’S OFFICE REPORTED NO COMMENT OTHER, AS SPECIFIED:

[COMMENTS OF GOVERNOR'S OFFICE ENCLOSED Govemor has waived review

LL] NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12, SIGN4TURE OF STATE AGENCY OFFICIAL: 16. RETURN TO:

Md UA LM. Patricia Pat) Taft 13, T¥PED NAME: ” . atricia (Pat) Taft , Vivianne M Chaumont Division of Medicaid & Long-Term Care

ia TITLE: : Nebraska Department of Health & Human Services

Director, Division of Medicaid and Long-Term Care 701 een NE ia Nall South 15. DATE SUBMITTED: ° a

September 29, 2010

FORM HCFA-179 (07.92)

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services

601 East 12" Street, Suite 235

Kansas City, Missouri 64106

Division of Medicaid and Children's Health Operations

Ms /

CENTERS for MEDICARE & MEDICAID SERVICES /

August 17, 2011

Vivianne Chaumont, Director Department of Health & Human Services Division of Medicaid and Long Term Care 301 Centennial Mall S., 5th Floor

PO Box 95026

Lincoln, Nebraska 68509

Dear Ms. Chaumont:

On May 18, 2011, the Centers for Medicare & Medicaid Services (CMS) received Nebraska’s State Plan Amendment (SPA) transmittal #11-08, which proposes to correct the fee schedule rate for secure psychiatric residential rehabilitation services with a

proposed effective date of June 1, 2011.

This SPA 11-08 was approved on August 16, 2011 with an effective date of June 1, 2011 as requested by the State. Enclosed is a copy of the CMS-179 form, as well as, the approved page for incorporation into the Nebraska State plan.

If you have any questions regarding this amendment, please contact Narinder Singh at

(816) 426-5925 or Narinder.Singh@cms.hhs.gov..

Sincerely

Enclosure

cc: Pat Taft

Jame$ G. Scott Assogiate Regional Administrator

or Medicaid and Children’s Health Operations

Revised Stlomission 7.a7II ATTACHMENT 4.19-B

Item 13d, Page 1a STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State Nebraska

METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES

SECURE PSYCHIATRIC RESIDENTIAL REHABILITATION

Medicaid has researched the cost of an existing similar service to develop a comparable rate. Costs for treatment and rehabilitation services are contained in the Medicaid rate. The rate does not include room and board. The rate for Secure Psychiatric Residential Rehabilitation was last updated on the fee schedule June 1, 2011 and is effective for services rendered on or after that date. Except as otherwise noted in the plan, State developed fee schedule rates are the same for quasi-governmental and private providers of Secure Psychiatric Residential Rehabilitation. See fee schedule at http:/Awww.dhhs.ne.gov/med/provhome.htm.

The State Medicaid agency will have a contract with each entity receiving payment under Secure Psychiatric Residential Rehabilitation services that will require that the entity furnish to the Medicaid agency on an annual basis the following:

e Data, by practitioner, on the utilization by Medicaid beneficiaries of the services included in the unit rate,

. Cost information by practitioner type and by type of service actually delivered within the services unit,

° Provider's annual utilization data and cost information shall support that the required

type, quantity and intensity of treatment services are delivered to meet the medical needs of the clients served. Medicaid Agency or its designee may further evaluate through on site or post pay review of the treatment plans and the specific services delivered as necessary to assure compliance.

COMMUNITY SUPPORT SERVICES

Community Support Services shall be reimbursed on a direct service by service basis and billed in 15 minute increments up to a maximum of 144 units per 180 days.

The rate for community support services was last updated on January 1, 2011, and is effective for services rendered on or after that date. Any annual/periodic adjustments to the fee schedule’ are published on the agency’s website at http://www.dhhs.ne.gov/med/provhome.htm.

This rate will be the same for quasi-governmental and private providers of community support service.

The rate includes all indirect services and collateral contacts that are medically necessary rehabilitative related interventions. |

TN: No. 11-08 Supersedes Approval Date AUG 16 2011 Effective Date TN No. NE 10-17

JUN 0 1 2011

DEPARTMENT OF HEALTH AND HUMAN SERVICES JALTH CARE ING ADMINISTRATION

FORM APPROVED ©

OMB NO, 0938-0193

IF APPROVAL OF

STATE PLAN MATERIAL

FOR: HEALTH CARE FINANCING ADMINISTRATION

SIONAL ADMINISTRATOR RE FINANCING ADMINISTRATION NTOF HEALTH AND HUMAN SERVICES

TOO RE

|

1. TRANSMITTAL NUMBER: 11-08

2. STATE Nebraska

3. PROGRAM IDENTIFICATION: TITLE XLX OF THE SOCIAL SECURITY ACT (MEDICAID)

ROPOSED EFFECTIVE DATE dune}, 2011

5. TYPE OF-PLAN MATERIAL (Check One):

(CV NEW STATE PLAN

(J) AMENDMENT'TO BE CONSIDERED AS. NEW PLAN

[] AMENDMENT

COMPL 3LOCKS 6 THRU 10 1F

‘HIS IS: AN AMENDM

* (Separate Transmittal for each amendment)

6. FEDERAL STATU EGULATION CITATION:

7. FEDERAL BUDGET IMPACT. aFFY 2011 . $0 b FRY 2012 $0

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

Attachment 4.19-B, Item 13d, p la

9, PAGE NUMBER-OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (if Applicable):

, Attachment 4.19-B, Item 13d, p la

j i | i

10. SUBJECT OF AMENDMENT;

Correction of the rate for Secure Psychiatric Residential Rehabilitation

“TT. GOVERNOR'S REVIEW (Check One): (1) GOVERNOR’S OFFICE REPORTED NO';COMMENT [] COMMENTS OF GOVERNOR’S OFFICE ENCLOSED

LL] NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

IX] OTHER, AS SPECIFIED: Governor has waived review

12. SIGNATURE OF S!

ae AGENCY. QEFICIAL: “13. TYPED NAME.

Vivianne M. Chaumoni

14. TITLE: Director, Division of Medicaid and Long-Term Care:

15. DATE SUBMITTED: May 18, 2011

16. RETURN TO:

Patricia (Pat) Taft

Division of Medicaid & l.ong-Term Care’ Nebraska Department of Health & Human Services 301 Centennial Mall South

- Lincoln, NE 68509

FOR RE GIONAL OFFICE USE ONLY

17. DATE RECEIVED:

May 18 Qoil

18. DA APPROVED:

~ : 4)

PLAN APPROVED - ONE

19, BE FEC TIVE DATE OF APP Saves MATERIALS

241. TYPED Ne AME:

Sames. G. “Scott

23. RE MARKS;

FORM HCFA-179 (07-92)

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services CIs 601 East 12" Street, Suite 235 Kansas City, Missouri 64106 CENTERS for MEDICARE & MEDICAID SERVICES Division of Medicaid and Children's Health Operations

December 23, 2011

Vivianne Chaumont, Director

Nebraska Department of Health & Human Services Division of Medicaid and Long-Term Care

301 Centennial Mall South, 3? Floor

PO Box 95026

Lincoln, Nebraska 68509

Dear Ms. Chaumont:

On September 27, 2011, the Centers for Medicare & Medicaid Services (CMS) received Nebraska State Plan Amendment (SPA), transmittal #11-14. Through this amendment the State is conforming with section 2302 of the Patient Protection and Affordable Care Act (Affordable Care Act), P.L. 111-148, which amended Title XIX (Medicaid) of the Social Security Act (the ACT) in requiring that children who are enrolled in either Medicaid or CHIP be allowed to receive hospice services without foregoing curative treatment related to a terminal illness effective July 1, 2011.

CMS approved SPA# 11-14 on December 21, 2011, with an effective date of July 1, 2011, as requested by the State. Enclosed is a copy of the CMS 179 form, as well as, the approved pages for incorporation into the Nebraska State pian. If you have any questions regarding this amendment, please call Sandra Levels at (816) 426-5925.

Sincerely,

Aor, Ald eh ly

Timothy A. Weidler

Acting Associate Regional Administrator

for Medicaid and Children’s Health Operations

Enclosure

cc: Cindy Kadavy Pat Taft

Revision: HCFA-PM-86-20 (BERC) ATTACHMENT 3.1-A SEPTEMBER 1986 Page 7

State/Territory: Nebraska

AMOUNT, DURATION AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY

15. a. _{ntermediate care facility services (other than such services in an institution for mental diseases) for persons determined in accordance with section 1902(a)(31)(A) of the Act, to be in need of such care.

_X_ Provided _ No limitations _X_ With limitations __ Not Provided:

b. Including such services in a public institution (or distinct part thereof) for the mentally retarded or persons with related conditions.

_X. Provided __ No limitations _X.. With limitations* _ Not Provided:

16. Inpatient psychiatric facility services for individuals under 22 years of age. _X_ Provided _X_ Nolimitations __ With limitations*

__ Not Provided:

7. Nurse-midwife services _X_ Provided __ No limitations _X.. With limitations* __ Not Provided: 18. Hospice care (in accordance with section 1905(0) of the Act). _X%_ Provided __.. No limitations _X__ Provided in accordance with section

2302 of the Affordable Care Act

_X_ With limitations*® _ Not Provided:

*Description provided on attachment

TN No. NE 11-14 Ree 21 201 wn 4 90 Supersedes Approval Date “ Effective Date JUL 0-1 201

TN No. 11-10

ATTACHMENT 3.1-A Item 18, Page 2 Applies to both Categorically and Medically Needy

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM

STATE OF NEBRASKA AMOUNT, DURATION AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED

LIMITATION ON THE AMOUNT, DURATION AND SCOPE OF CERTAIN ITEMS OF PROVIDED MEDICAL AND REMEDIAL CARE AND SERVICES ARE DESCRIBED AS FOLLOWS.

Certification of Terminal fliness

The client must be certified as terminally ill with a six-month life expectancy by the Hospice medical director and the attending physician at the beginning of the first benefit period and by the Hospice medical director for all subsequent benefit periods. The hospice provider must obtain written certification of the terminal illness for each certification period even when a single election continues in effect for two or more periods.

Plan of Care

Awritten plan of care must be established and maintained for each client admitted to a hospice program. The care provided to a client must be consistent with the plan and be reasonable and necessary for the palliation or management of the terminal iliness as well as related conditions. The plan of care must be established before services are provided.

Waiver of Payment for Other Services

A client waives all rights to Medicaid payments for the duration of the election of hospice care for the following services:

Hospice care provided by a hospice other than the hospice designated by the client; and

For adult clients, any Medicaid services that are related to the treatment of the terminal condition for which hospice care elected or a related condition or that are equivalent to hospice care except for services provided:

by the designated hospice: or the client's attending physician if that physician is not an employee

of the designated hospice or receiving compensation from the hospice for those services.

TN No, NE 11-14 oe ot 20 a? Supersedes Approval Date Effective Date TN No, MS-04-02

Revision. HCFA-PM-85-3 (BERC) ATTACHMENT 3.1-B SEPTEMBER 1986 Page 6

State/Territory: Nebraska

AMOUNT, DURATION AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE MEDICALLY NEEDY

c. Intermediate care facility services. _X_ Provided _. No limitations _X_ With limitations*

415. a. Intermediate care facility services (other than such services in an institution for mental diseases) for persons determined in accordance with section 1902(a)(31)(A) of the Act, to be in need of such care.

_X_ Provided _ No limitations _X_ With limitations*

b. Including such services in a public institution (or district part thereof) for the mentally retarded or persons with related conditions.

_X_ Provided __ No timitations X. With limitations* 16, Inpatient psychiatric facility services for individuals under 22 years of age. X_ Provided _X_ No limitations _. With limitations*

17, Nurse-midwife services.

_X_ Provided __ No limitations _X_ With limitations*

18, Hospice care (in accordance with section 1905(0) of the Act).

_X_ Provided __. No limitations _X_ Provided in accordance with section 2302 of the Affordabie Care Act

_X_ With limitations*

*Description provided on attachment -

TN No. NE 11-14 wee 21 Dot JUL 07 a Supersedes Approval Date vk 1 a Effective Date 01 dull

TN No, 11-10

DEPARTMENT OF HEALTH AND HUMAN SERVICES

FORM APPROVED OMB NO. 0938-9193

HEALTH CARE BINANCING ADMINISTRATION TRANSMITTAL AND NOTICE OF APPROVAL OF 1. TRANSMITTAL NUMBER: 2. STATE STATE PLAN MATERIAL NE {1-14 Nebraska

FOR: HEALTH CARE FINANCING ADMINISTRATION

3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID)

TO: REGIONAL ADMINISTRATOR HEALTH CARE FINANCING ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES

4, PROPOSED EFFECTIVE DATE 74-ll

5. TYPE OF PLAN MATERIAL (Check One):

[J NEW STATE PLAN

(] AMENDMENT 10 BE CONSIDERED AS NEW PLAN

AMENDMENT

COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment)

6. FEDERAL STATUTE/REGULATION CITATION:

7, FEDERAL BUDGET IMPACT: a FFY 2011 § 88,i44 b, FF¥_ 2012 $ 352,576

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT,

Attachment 3.1-A, page 7 Attachment 3.1-A, Item 18, page 2 Attachment 3.1-B, page 6

9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (Uf Applicable):

Attachment 3.1-A, page 7 Attachment 3.1-A, Item 18, page 2 Attachment 3.1-B, page 6

10. SUBJECT OF AMENDMENT; Concurrent curative care for children receiving hospice service.

1H, GOVERNOR’S REVIEW (Check One): (] GOVERNOR’S OFFICE REPORTED NO COMMENT ([] COMMENTS OF GOVERNOR'S OFFICE ENCLOSED (NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

kX] OTHER, AS SPECIFIED: Governor has waived review

12, S$]

gNATURE OF S$! , Ye E AGE OFE.

13. TYPED NAME: Vivianne M. Chaumont

14, TITLE: Director, Division of Medicaid and Long-Term Care

15. DATE SUBMITTED: September 26, 2011

16, RETURN TO:

Patricia (Pat) Taft

Division of Medicaid & Long-Term Care Nebraska Department of Health & Human Services 301 Centennial Mall South

Lincoln, NE 68509

__FOR REGIONAL OFFICE USE ONLY

17. DATE RECEIVED:

S eptember 21,201

PPROVED:;

18, DATE ecéon her fl OM

PLAN APPROVED — ONE COPY ATTACHED

19. EFFECTIVE DATE OF APPROVED MATERIAL: 20, SIGNASURE EOL BGC YO Duly 1, 20M 21. TYPED NAME: ~ 22. TITLE: an LMS Regional” Adminsivaker

Pp. Weidler

Sor Medicaid GAd Chi Berens HEL Lperedti ons.

Lon otha 23, REMARKS: J

FORM HCFA-179 (07-92)

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services

601 East 12" Street, Suite 235

Kansas City, Missouri 64106

Division of Medicaid and Children's Health Operations October 14, 2011

Vivianne Chaumont, Director

Nebraska Department of Health & Human Services. Division of Medicaid & Long Term Care

301 Centennial Mall S., 5th Floor

PO Box 95026

Lincoln NE 68509

Dear Ms. Chaumont:

On August 17, 2011, the Centers for Medicare & Medicaid Services (CMS) received Nebraska's State Plan Amendment (SPA), transmittal # 11-15, revising the State’s Tribal consultation process. This SPA added language changing the current process of Tribal consulting on all proposed SPAs and waivers regardless of impact, to not providing Tribal consultation on SPAs that are purely technical in nature (i.e. pagination changes, renumbering of lists, etc.) and therefore; have no direct impact on the Tribes. This SPA also provided evidence of your continued process of informing and seeking input from all federally recognized Native American Tribes and Indian Health Programs within the State of Nebraska regarding all other SPAs and waivers, the overall Tribal consultation process and required timeframes; as well as, discussing any possible impact proposed SPAs might have on the Tribes.

Based on the information provided, this SPA is approved as of October 43, 2011, with an effective date of July 1, 2011 as requested by the State. Enclosed is a copy of the CMS 179 form as well as the approved pages for incorporation into the Nebraska State Plan. If you have any questions regarding this amendment, please call Gail Brown Stevenson at (816) 426-5925.

g ate Regional Administrator for Medicaid and Children’s Health Operations

Enclosure cc: Pat Taft Sam Kaplan

Margaret Ahola

Submission 4 1a./1

Rev ised

Approved OMB#: 0938-1098

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State: Nebraska

1.4 State Medical Care Advisory Committee (42 CFR 431 .12(b))

There is an advisory committee to the Medicaid agency director on health and medical care services established in accordance with and meeting all the requirements of 42 CFR

431.12.

_X___s The State enrolls recipients in MCO, PIHP, PAHP, and/or PCCM programs. The State assures that it complies with 42 CFR 438.104(c) to consult with the Medical Care Advisory Committee in the review of marketing materials.

Tribal Consultation Requirements Section 1902(a)(73) of the Social Security Act (the Act) requires a State in which one or

more Indian Health Programs or Urban Indian Organizations furnish health care services to establish a process for the State Medicaid agency to seek advice on a regular, ongoing basis from designees of Indian health programs, whether operated by the Indian Health Service (IHS), Tribes or Tribal organizations under the Indian Self-Determination and Education Assistance Act (ISDEAA), or Urban Indian Organizations under the Indian Health Care Improvement Act (IHCIA). Section 2107(e)(1) of the Act was also amended to apply these requirements to the Children’s Health Insurance Program (CHIP). Consultation is required concerning Medicaid and CHIP matters having a direct impact on Indian health programs and Urban Indian organizations.

Please describe the process the State uses to seek advice on a regular, ongoing basis from federally-recognized tribes, Indian Health Programs and Urban Indian Organizations on matters related to Medicaid and CHIP programs and for consultation on State Plan Amendments, waiver proposals, waiver extensions, waiver amendments, waiver renewals and proposals for demonstration projects prior to submission to CMS. Please include information about the frequency, inclusiveness and process for secking such advice.

- The Division of Medicaid and Long-Term Care (MLTC) meets on a quarterly basis or as needed with the tribes (Omaha, Ponca, Santee Sioux and Winnebago) and with the CMS Native American contact to discuss relevant Medicaid/CHIP matters that impact the tribes and to invite discussion and comments for consideration.

Effective September 1, 2010, MLTC implemented a policy regarding seeking consultation from all federally recognized tribes, Indian Health Service and Urban Indian Organizations within the state regarding State Plan Amendments (SPA), proposals for demonstrations, and waivers, including proposed, extensions, amendments and renewals,

TN No: 11-15 o Supersedes Approval Date -OCT 13 2011 Effective Date 1" 0.1 201

TN No. MS 03-12

Revised Submisstor g.1D.1

OL

(1.4 continued)

which may have an impact on those entities. All proposed SPA’s, waivers, and demonstrations will be sent to the Tribes for comment, not just those that we believe will directly impact the tribes. However, purely technical changes that have no impact on the substance of the topic (such as pagination, renumbering of lists, etc.) will not be submitted to the Tribes.

Proposed SPA’s, waivers, and demonstrations are routed to the tribes for comment/input prior to submitting to CMS. The Division of Medicaid and Long-Term Care consults with the tribes by notifying designated tribal entities electronically via email with a description of the proposed change(s). The tribal liaison, which is a position designated by the Division of Medicaid and Long-Term Care, is responsible for maintaining a complete list of iribal contacts and their respective email and mailing addresses. The tribal contact list is updated at the tribal consultation meetings and was last updated at the tribal consultation meeting held in November, 2010, The proposed SPA, waiver, or demonstration is submitted to Tribal Clinics, Health Centers, the IHS Hospital, and to the Nebraska Urban Indian Health Coalition for comment. MLTC allows the tribes 60 days to respond. If nothing is heard from the Tribes by the end of the stated time period, MLTC is then in a position to submit the SPA, waiver or demonstration to CMS. The CMS Native American Contact is copied in this process by the MLTC to telegraph our

efforts to secure comments/input from the Tribes.

If comments are; in fact, received from the tribes, the same is relayed to the Division Director for further consideration. If one tribe has a question or concern about a SPA, waiver amendment, waiver extension, waiver renewal or demonstration proposal, that concern would be communicated and transmitted electronically via e-mail to all other tribes and tribal entities by the tribal liaison. Such communication will specify who raised the concern or comment, the specific nature of the concern or comment, and what the Department proposed to do in response to that concern or comment in an attempt to address or resolve the concern. A management decision is then made as to whether additional action (telephone conferences, meetings, research, etc.) would be appropriate under the circumstances prior to submitting the SPA, waiver or demonstration to CMS.

Comments from the Tribes, or the lack of comments/response, are reported to the CMS Native American Contact, as well as our response/resolution to those comments.

The consultation process established by the Department is based in part on face to face visits and discussions with various tribal entities and the Nebraska Department of Health and Human Services. At the November 29, 2010 meeting, discussions were initiated relating to the proposed SPA consultation process. Tribal Liaison shared the written policy of the Department as it existed at that time regarding the proposed consultation

TN No: 11-15 4 Supersedes _ Approval Date_ OCT 15 201 Effective Date 12 0.1 2011 TN No. New Page

Q euised Submission &.]5.18

9.2

(1.4 continued)

process, Comments from the tribes regarding the process and how it might impact the tribes were noted and later expressed Lo state Medicaid management. At the November meeting, it was proposed by the Department that the tribes be given notice regarding all proposed SPA’s and waivers, not just those that the Department thought might have some impact on the tribes, Some members expressed the Department should indicate to the tribes which SPA’s and waivers had a direct impact on the tribes in its opinion, The tribes also expressed that it would be helpful to have a process in place to share comments and Department responses to those comments during the consultation process. These suggestions were discussed with Medicaid administrators and adopted by the Department. Current policy is that if one tribe has a question or concern about a SPA or waiver, that concern will be made known to all the tribal entities by the Department, as well as making it known how the Department attempted to resolve the concern,

In order to facilitate the consultation process, the Department will, in advance of the consultation meeting, provide the tribes with a formal agenda describing the SPA’s and waivers that might have relevance to the tribes, as well as other information that will be addressed by the Department. The Department will take minutes of the meeting, which will be available on request, and maintain a record of the same. The Department will ensure that a current roster of participants is kept and maintained, indicating participant’s names, addresses, telephone numbers, and with which group they are associated.

Please describe the consultation process that occurred specifically for the development and submission of this State Plan Amendment, when it occurred and

who was involved.

Initial Amendment In January of 2010, the State received guidance from CMS, SMDL# 10-001, that set forth

the general requirements expected of States to alert tribal entities to proposed State Plan Amendments, waivers, and demonstrations. On February 18, 2010, a Nebraska State/Tribal Consultation Meeting was held. Attending were representatives from the various Tribes in Nebraska, Indian health providers, the Native American Contact from CMS, the Nebraska Medicaid tribal liaison, and the Nebraska Medicaid Director. The tribal consultation issue was discussed in general terms at the meeting and the Tribes expressed a desire to become involved in the consultation process.

Following this, a written process was developed by Nebraska Medicaid outlining the process for the State to follow to secure consultation with the Tribes prior to the State

TN No: [1-15 aye Supersedes Approval Date__QCT_1 3 2011 -—- Effective Date fH Ol 2011

TN No. New Page

Revi 5ed Submission

9.3

(1.4 continued)

submitting a SPA, waiver, or demonstration, The proposed process was reviewed and approved by Nebraska Medicaid administration. In June, 2010, the protocol for consultation was shared with Medicaid Division staff and sent to the tribal entities.

In October 2010, the State received additional guidance from CMS regarding the consultation process required with tribal entities prior to submitting a SPA, waiver, or demonstration to CMS. The additional guidance required that states give the Tribes a sixty day period to consult. The guidance suggested that states should submit to the Tribes a comprehensible summary of the effect of the proposed SPA, waiver, or demonstration rather than merely submitting the SPA, waiver, or demonstration documents. Nebraska Medicaid revised the protocol for submitting a SPA, waiver, or demonstration and securing tribal consultation and communicated to Medicaid Division staff. On November 2, 2010, the State notified all tribal entities its intent to submit a SPA regarding the tribal consultation process. The letter outlined a summary of the consultation process set forth in the revised protocol.

The tribal consultation issue was discussed in detail at a November 29, 2010 Nebraska State/Tribal Consultation Meeting. Attending were representatives from the various Tribes in Nebraska, Indian health providers, the Native American Contact from CMS, and the Nebraska Medicaid tribal liaison. The tribal consultation issue was discussed in

detail at the meeting.

Current Amendment A communication was sent to all tribal entities June 2, 2011, advising them of the

technical changes and it was also discussed at a meeting with them July 12, 2011.

TN No: 11-15 wes Supersedes Approval Date. OCT 13 2011 Effective Dato_ it. O 1 2011 TN No. New Page

According to the Paperwork Reduction Act of 1995, no persons are required to respond toa collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1098. The time required to complete this information collection is estimated to average 1 hour per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write fo: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

CMS-10293 (07/2013)

Revised Submigsio, Ff: Io.

DEPARTMENT OF HEALTH AND HUMAN SERVICES

FORM APPROVED OMB NO. 0938-0193

HEALTH CARE FINANCING ADMINISTRATION TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL

2. STATE

1. TRANSMITTAL NUMBER: Nebraska

[1-15

FOR: HEALTH CARE FINANCING ADMINISTRATION

3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID)

TO: REGIONAL ADMINISTRATOR HEALTH CARE FINANCING ADMINISTRATION

DEPARTMENT OF HEALTH AND HUMAN SERVICES

4. PROPOSED EFFECTIVE DATE July 1, 2011

5. TYPE OF PLAN MATERIAL (Check One):

(J NEW STATE PLAN

(] AMENDMENT TO BE CONSIDERED AS NEW PLAN

BQ) AMENDMENT

COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmitiat ‘for each ginendment)

6. FEDERAL STATUTE/REGULATION CITATION:

7, FEDERAL BUDGET IMPACT: a. FFY 2011 $0 b. FFY__ 2012 $0

&. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

Section 1.4, pages 9, 9.1, 9.2, 9.3,

> PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (if Applicable):

Section I, 1.4, pages 8, 8a, 8b, 8c (TN #10-05} and page 9 (MS- 03-12)

10. SUBJECT OF AMENDMENT:

‘Tribal consultation exception for technical changes and correcting page numbers.

11. GOVERNOR’S REVIEW (Check One): (C] GOVERNOR'S OFFICE REPORTED NO COMMENT {-] COMMENTS OF GOVERNOR’S OFFICE ENCLOSED (NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

[XJ OTHER, AS SPECIFIED: Governor has waived review _

12. SIGNATUBp OF STATE AGENCY, OFFICIAL; Minune He.

16, RETURN TO:

Patricia (Pat) Taft

13. TYPED NAME: Viviarme M, Chaumont

Division of Medicaid & Long-Term Care Nebraska Department of Health & Human Services

14. TITLE: Director, Division of Medicaid and Long-Term Care

301 Centennial Mall South Lincoln, NE 68509

15. DATE SUBMITTED: August 17, 2011

FOR REGIONAL OFFICE USE ONLY

APPROVED:

18, DA! L3.2oll

17. DATE RECEIVED: August [72011

7 PLAN APPROVED ~— ONE COPY 4) PAC

(LZ 19. EFFECTIVE DATE OF APPROVED MATERIAL: 20, SIGRR E ON JiOMA Ake 31. TYPED NAME; —— Y ’ C s x : P 9 Tad, on Dames G. Scott ) - Meddcaid Gad Chidran's Heahtl Qoeretions

23. REMARKS:

FORM HCFA-179 (07-92)

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services

7500 Security Boulevard, Mail Stop $2-26-12 Baltimore, Maryland 21244-1850

Lincoln, Nebraska 68509 RE: Nebraska State Plan Amendment TN: 11-16

Dear Ms. Chee

ander ‘transmittal number (TN) iL 16. Efeotive April 1, 2011, this amendment prop utionate Share Hospital (DSH) payment methodology to comply with the

llow for a recoupment and redistribution process for any DSH overpayments DSH audit.

2011. We are gale. the HCFA-179 and the amended plan p pages.

If you have any questions, please call Tim Weidler at (816) 426-6429.

Sincerely,

(Ay Mane—A indy Ma

Director, CMCS

Enclosures

ATTACHMENT 4.19-A Page 21c

10-010.03H4 Redistribution of DSH Overpayments: As required by Section 1923()) of the Social Security Act related to auditing and reporting of Disproportionate Share

Hospital payments, the Department will implement procedures to comply with the Disproportionate Share Hospital Payments final rule issued in the December 19, 2008, Federal Register, with effective date of January 19, 2009.

Beginning in DSH State Plan Rate Year 2011, if the results of audits conducted in accordance with the DSH final rule indicate that a hospital has exceeded the hospital specific DSH limit the amount of DSH payment in excess of uncompensated care costs will be recouped. Any funds recouped shail first be recouped from Pool 1 | through 5 payments and then from Pool 6 payments and shall be redistributed to other eligible hospitals within the state, provided each hospital remains below their hospital specific DSH limit. Funds recouped from Pools 1 through 6 shall first be redistributed to each eligible hospital in the Pool in which the hospital payment was recouped. Any recouped funds that are not able to be distributed within the Pool will accumulate and be redistributed to all eligible hospitals. The Department will calculate the redistribution as follows: 1. Pool Redistribution

a. First, for each Pool in which funds were recouped beginning with Pool 1 and proceeding in Pool numerical order, each hospital's difference between their DSH payment and DSH limit will be calculated. The difference will be divided by the sum of the difference between the DSH payment and DSH limit for all hospitals in the Pool.

b. Second, the ratio resulting from such division will be multiplied times the total funding recouped for the Pool to determine each hospital's redistribution payment.

c. If the sum of the original DSH payment and redistribution payment exceeds the DSH payment limit, the payment will be reduced.

d. If payment is reduced to a hospital within a Pool, the additional funds will be redistributed prorata to eligible hospitals within the Pool. If all hospitals within the Pool have reached their DSH limit, the remaining funds will be carried forward to be redistributed to all eligible hospitals. For Pool 6, each hospital's difference between their DSH payment and DSH limit will include funds redistributed from Pools 1 through 5 above.

2. Final Redistribution

a. First, for any funds that were not redistributed for each Pool in which funds were recouped, each hospital’s (except for Pool 4 IMDs) difference between their DSH payment and DSH limit will be calculated. The difference will be divided by the sum of the difference between the DSH payment and DSH iimit for all'non-IMD hospitals.

b. Second, the ratio resulting from such division will be multiplied times the total recouped funding not already distributed to determine each hospital's redistribution payment.

c. {f the sum of the original DSH payment and redistribution payment exceeds the DSH payment limit, the payment will be reduced.

d. If payment is reduced to a hospital, the additional funds will be redistributed prorata to eligDible non-IMD hospitals within the Pool. If all non-IMD hospitals have reached their DSH limit, the federal portion of remaining funds will be retumed to CMS.

TN No. NE 11-16 MAR = 3 20i2 Supersedes Approval Date Effective Date APA ~ 4% 2071 TN No. New Page

as Ve ere

ATTACHMENT 4.19-A- Page 21b

40-010.03H3a(6) Uncompensated Care Pool (Pool 6): Pool 6 consists of hospitals that provide services to low-income persons covered by a county administered general assistance (GA) program; or hospitals that provide services to low-income persons covered by the state administered public behavioral health system.

. 10-010,03H3a(6)(a) Total funding to Pool 6 will be the remaining balance. , of the total (federal and state) DSH funding minus the funding for Pools 1, 2, 3, 4, and 5, The Department will calculate payments as follows:

1. .DSH payments to a hospital under all other pools will be subtracted from the hospital's DSH upper payment limit before \ allocating payments under Pool 6. : 2. The costs for uncompensated care resulting from participation in - county administered general assistance (GA) program will be , reported by the county; and costs for the state administered public behavioral health system will be reported by each hospital. Reported costs will be subject to audit by the Department. 3. A ratio for each hospital will be determined based on the uncompensated cost for each hospital to the total of uncompensated cost for all hospitals in Pool 6. 4. The ratio for each hospital will be multiplied times the available funding to the Pool to yield each hospital’ annual payment amount. 5. The total computable payment will be commensurate with the charges for uncompensated care resulting from participation in county administered general assistance (GA) program; or the state administered public behavioral health system. 6. The annual payment amount will be dispersed in twelve monthly payments. 7. If payment to the hospital exceeds the disproportionate share payment limit, as established under 1923(f) of the Social Security Act, the payment will be reduced to the payment limit. 8. {f payments to hospitals under this pool exceed the total allotment - to Nebraska, the payments will be reduced prorata.

10-010.03H3b Limitations on disproportionate share payments: (1) No payments made under this section will exceed any applicable imitations upon such payments established by Section 1923 (g)(1)(A) of the Social Security Act. (2) Disproportionate share payments to all qualified hospitals for a year will not exceed the State disproportionate share hospital payment limit, as established under 1923 (f) of the Social Security Act.

TN No, 114-16 ‘ MAR = % 2012 Supersedes Approval Date Effective Date APR ~ 1 20t] TN No. MS 06-02 ; ‘

\

ATTACHMENT 4,19-A Page 22

40-010.03J Out-of-State Hospital Rates: The Department pays out-of-state hospitals for hospital inpatient services at the peer group rate for a like peer group of Nebraska hospitals. The peer groups are -

1. Metro Acute Care Hospitals: Hospitals located in a Metropolitan Statistical Area (MSAs) as designated by Medicare;

3. Rural Acute Care Hospitals: All other acute care hospitals;

4. Psychiatric Hospitals and Distinct Part Units in Acute Care Hospitals: Hospitals that are licensed as psychiatric hospitals by the licensing agency of the state in which the hospital is located and distinct parts as defined in 471 NAC 10-010.03A.

5. Rehabilitation Hospitals and Distinct Part Units in Acute Care Hospitals: Hospitals that are licensed as rehabilitation hospitals by the licensing agency of the state in which the hospital is located and distinct parts as defined in 471 NAC 10-010.03A.

Operating cost payment amounts are calculated based on the appropriate peer group base payment amount. Capital-related cost payments are made based on the peer group weighted median capital per diem rate. Effective September 1,

2003, capital costs will be calculated as 96.85% of the peer group weighted median cost per day. The cost-to-charge ratio is the peer group average.

Payments for psychiatric and rehabilitation services provided by out-of-state hospitals are made on a prospective per diem. Hospitals are paid based on the peer group per diem rate for the appropriate type of service. Operating cost payment amounts are calculated based on the appropriate peer group per diem rate. Capital-related cost payments are made based on the peer group weighted median capital per diem rate.

The Department may allow payments to out-of-state hospitals for direct or indirect medical education costs at a negotiated per discharge rate.

40-010.03J1 Exception: The Administrator of the Medicaid Division may enter into an agreement with an out-of-state hospital for a rate that exceeds the rate or fee established in 471 NAC 10-010.03J only when the Medical Director of the Department has determined that-

1. The client requires specialized services that are not available in Nebraska; and

2. No other source of the specialized services can be found to provide the services at the rate established in 471 NAC 10-010.03J.

40-010.03K Out-of-Plan Services: When enrollees in the Nebraska Health Connection are provided hospital inpatient services by facilities not under contract with the Department's prepaid health care organizations, the Department contracted prepaid health care organizations are authorized, but are not required, to pay providers of hospital inpatient services who care for individuals enrolled in the Nebraska Health Connection at rates the Department would otherwise reimburse providers under 471NAC 10-010.03ff.

TN No, 11-16 = 4 ot Supersedes Approval Date WAR ~ 3 2012 Effective Date APR ~ 12041

TN No. MS-03-06

OS Notification State/Title/Plan Number: NE 11-016 Type of Action: SPA Approval Required Date for State Notification: 03/18/2012

Fiscal Impact: . FY 2011 $-0- FY 2012 $-0-

Number of Services Provided by Enhanced Coverage, Benefits or Retained Enrollment: 0

Number of Potential Newly Eligible People: 0

Eligibility Simplification: No

Provider Payment Increase: No

Delivery System Innovation: No Number of People Losing Medicaid Eligibility: 0 Reduces Benefits: No

Detail:

Effective April 1, 2011, this amendment modifies the Disproportionate Share Hospital (DSH) payment methodology to comply with the DSH Auditing and Reporting final rule that became effective on January 19, 2009. Provisions are being added to allow for a recoupment and redistribution process for any DSH overpayments identified during the DSH audit.

Other Considerations: Prior to submitting this SPA, the Nebraska Division of Medicaid Long-Term Care sought consultation from federally recognized Native American Tribes with the State to discuss the impact that the proposed SPA might have, if any, on the Tribes. No comments were received.

We do not recommend the Secretary contact the governor.

CMS Contact: Tim Weidler, NIRT 816-426-6429

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION, __OMB NO, 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF 1, TRANSMITTAL NUMBER: 2. STATE STATE PLAN MATERIAL 11-16 Nebraska

FOR: HEALTH CARE FINANCING ADMINISTRATION

3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID)

TO: REGIONAL ADMINISTRATOR HEALTH CARE FINANCING ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES

4, PROPOSED EFFECTIVE DATE April 1, 2011

5. TYPE OF PLAN MATERIAL (Check One):

(C1 NEW STATE PLAN

(7 AMENDMENT TO BE CONSIDERED AS NEW PLAN

AMENDMENT

COMPLETE BLOCKS 6 THRU 10 IF. THIS IS AN AMENDMENT (Separate Transmittal for each amendment)

6. FEDERAL STATUTE/REGULATION CITATION:

7, FEDERAL BUDGET IMPACT: a. FFY 2011 $0 b. FFY 2012 $0

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

Attachment 4.19-A, pages 21b, 21¢ and 22

9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (if Applicable):

Attachment 4.19-A, page 21b, and 22

10. SUBJECT OF AMENDMENT: Distribution of disproportionate share hospital overpayments.

11. GOVERNOR’S REVIEW (Check One):

(CU GOVERNOR’S OFFICE REPORTED NO COMMENT OTHER, AS SPECIFIED: [1 COMMENTS OF GOVERNOR’S OFFICE ENCLOSED Governor has waived review [INO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

12. Lae, OF STATE RON OFFICIAL: 16. RETURN TO:

13. TYPED NAME: Patricia (Pat) Taft

Vivianne M, Chaumont

14, TITLE: Director, Division of Medicaid and Loi omg: Term ¢ cn.

Division of Medicaid & Long-Term Care Jepartrs it of Health & Human Services nial. Mali South

15. DATE SUBMITTED: ne 29, 2011

£48502 .

FOR cRIONAL OFFICE USE ONLY

17. DATE RECEIVED:

18. DATE APPROVED:

MAR ~ 2 2012

PLAN APPROVED — ONE COPY ATEACHED

19. EFFECTIVE DATE OF APPROVED MARpRAL: i oii

21. TYPED NAME:

oy

Cate (hom PSou

20. a aoe REGIONAL OFFICIAL: 22,

Es puny Deca, Cmcs

23. REMARKS:

FORM HCFA-179 (07-92)

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services C/V. Ay 601 East 12" Street, Suite 355 : Kansas City, Missouri 64106 CENTERS for MEDICARE & MEDICAID SERVICES Division of Medicaid and Children's Health Operations

March 7, 2012

Vivianne Chaumont, Director Department of Health & Human Services Division of Medicaid and Long Term Care 301 Centennial Mail S., 5th Floor

PO Box 95026

Lincoln, Nebraska 68509

Dear Ms. Chaumont:

On August 10, 2011, the Centers for Medicare & Medicaid Services (CMS) received Nebraska’s State Plan Amendment (SPA) transmittal #11-019, which proposes to reduce the fee schedule rate for physician services by 2.5% with a proposed effective date of July 1, 2011.

This SPA 11-19 was approved on March 6, 2012 with an effective date of July 1, 201,1 as requested by the State. Enclosed is a copy of the CMS-179 form, as well as, the approved page for incorporation into the Nebraska State plan.

If you have any questions regarding this amendment, please contact Narinder Singh at (816) 426-5925 or Narinder.Singh@cms.hhs.gov.

ASSociate Regional Administrator for Medicaid and Children’s Health Operations

Enclosure

cc: Pat Taft

ATTACHMENT 4,19-B Item 5, Page 1

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State Nebraska

METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES

PHYSICIANS' SERVICES

For dates of service on or after August 1, 1989, NMAP pays for covered physicians’ services at the lower of: 1. The provider's submitted charge; or 2. The allowabie amount for that procedure code in the Nebraska Medicaid Practitioner Fee Schedule in effect for that date of service. The allowable amount is indicated in the fee schedule as: a. The unit value multiplied by the conversion factor (last updated on July 1, 2010); b. The invoice cost (indicated as "IC" in the fee schedule); or c. The reasonable charge for the procedure as determined by the Medicaid Division (indicated as "BR" - by report or "RNE" - rate not established - in the fee schedule). 3. Exception: The Director of the Division of Medicaid and Long-Term Care or designee may enter into an agreement for a negotiated rate with an out-of-state provider which will be based on a percentage of billed charges, not to exceed 100%, only when the Medical Director of the Division has determined that: a. The client requires specialized services that are not available in Nebraska; and b. No other source of the specialized service can be found.

The following is a listing of specialized physician services that have been previously rendered by out-of-state providers:

a. lung transplants; and

b. pediatric heart transplants.

Note: The above listing is not all-inclusive of the specialized physician services that will be reimbursed via negotiated rates in the future, as it is based on previous experience.”

The Nebraska Medicaid Practitioner Fee Schedule was last updated on July 1, 2011 and is effective for services rendered on or after that date. The fee schedule is subject to annual/periodic adjustment. All rates, including current and prior rates, are published and maintained on the agency’s website. Specifically, the fee schedule and any annual/periodic adjustments to the fee schedule are published at htto://www.dhhs ne.gov/med/practitioner fee_schedule.htm.

Physicians and non-physician care providers are subject to a site-of-service payment adjustment. A site-of-service differential that reduces the fee schedule amount for specific CPT/HCPCS codes will be applied when the service is provided in the facility setting. Based on the Medicare differential, NMAP will reimburse specific CPT/HCPCS codes with adjusted rates based on the site-of-service.

The Nebraska Medicaid Practitioner Fee Schedule is effective July 1 through June 30 of each year.

IN# 1418 _MAR 0 6 2012 Effective Date JUL 0 1 201)

Supersedes Approval Date TN #.NE 10-08

DEPARTMENT OF HEALTH AND HUMAN SERVICES HEALTH CARE FINANCING ADMINISTRATION

FORM APPROVED OMB NG. 0938-0193

TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL

FOR: HEALTH CARE FINANCING ADMINISTRATION

1). TRANSMITTAL NUMBER: 2. STATE 11-19 Nebraska

3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCTAL SECURITY ACT (MEDICAID)

TO: REGIONAL ADMINISTRATOR HEALTH CARE FINANCING ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES

4, PROPOSED EFFECTIVE DATE July 1, 201)

5. TYPE OF PLAN MATERIAL (Check One);

(] NEW STATE PLAN

[] AMENDMENT TO BE CONSIDERED AS NEW PLAN

AMENDMENT

COMPI

E BLOCKS 6 THRU 10 If THIS IS AN AMENDMENT (Separate Transmittal for each amendment)

6. FEDERAL STATUTE/REGULATION CITATION:

7. FEDERAL BUDGET IMPACT: a. FFY 201! $(130,990) 6b FEY 2012 $(392,969)

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

Attachment 4,19-B, [tem 5, p. |

9, PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (f Applicable):

Attachment 4.19-B, [tem $, p. |

10. SUBJECT OF AMENDMENT: Physician Fee Schedule Reduction

11. GOVERNOR’S REVIEW (Check One): (J GOVERNOR'S OFFICE REPORTED NO COMMENT [] COMMENTS OF GOVERNOR’S OFFICE ENCLOSED

(] NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

EJ OTHER, AS SPECIFIED: Governor has waived review

12, 0 ie STATE AGENCY OFFICIAL;

13, TYPED NAME: Vivianne M. Chaumont

Director, Division of Medicaid and Long-Term Care

18. DATE SUBMITTED: August 10, 2011

16. RETURN TO:

Patricia (Pat) Taft

Division of Medicaid & Long-Term Care Nebraska Department of Health & Human Services 301 Centennial Mal! South

Lincoln, NE 68509

FOR REGIONAL OFFICE USE ONLY

17, DATE RECEIVED: D / ' Ugust 220)

7PLAN APPROVED —- ONE COPY:

oon

19. EPFECTIVE DATE OF APPROVED MATERIAL:

ff 20.8) JURHKONBEGIONZ# OFFICIAL:

ulu | del! 21. TYPED NAME. Jf 22. {ITLE: OLiGAS ioneh Admial strata ames..G.... cut editald BadCAt dean's. Health. oeehoos

23, REMARKS:

FORM HCFA-179 (07-92)

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services < i,7 hy 601 East 12" Street, Suite 235 .

Kansas City, Missouri 64106 CENTERS for MEDICARE & MEDICAID SERVICES

Division of Medicaid and Children's Health Operations December 23, 2011

Vivianne Chaumont, Director

Nebraska Department of Health & Human Services Division of Medicaid & Long Term Care

301 Centennial Mail S., Sth Floor

PO Box 95026

Lincoln NE 68509

Dear Ms. Chaumont:

On September 26, 2011, the Centers for Medicare & Medicaid Services (CMS) received Nebraska’s State Plan Amendment (SPA), transmittal # 11-20, to update the effective date of rates for Pediatric Feeding Disorder Clinic Intensive Day Treatment Services.

Based on the information provided, this SPA is approved as of December 22, 2011, with an effective date of July 1, 2011, as requested by the State. Enclosed is a copy of the CMS 179 form, as well as, the approved pages for incorporation into the Nebraska State Plan. If you have any questions regarding this amendment, please call Narinder Singh at (816) 426-5925.

Sincerely,

Timothy A. Weidler Acting Associate Regional Administrator for Medicaid and Children’s Health Operations

Enclosure

cc: Pat Taft Margaret Booth Nancy Keller

ATTACHMENT 4.19-B Item 9, Page 5

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State Nebraska METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES

Pediatric Feeding Disorder Clinic Intensive Day Treatment: Reimbursement for pediatric feeding disorder clinic intensive day treatment for medically necessary services will be a bundled rate based on the sum of the fee schedule amounts for covered services provided by Medicaid enrolled licensed practitioners. This service is reimbursed via a daily rate.

Pediatric Feeding Disorder Clinic Qutpatient Treatment: Reimbursement for Pediatric Feeding Disorder Clinic Outpatient Treatment for medically necessary services will be based on the appropriate fee schedule amount for a physician consultation. This service is reimbursed via an encounter rate.

An encounter means a face-to-face visit between a Medicaid-eligible patient and a physician, psychologist, speech therapist, physical therapist, or dietician during which services are rendered. Encounters with more than one health professional and multiple encounters with the same health professional which take place on the same day and at a single location constitute a single visit.

Except as otherwise noted in the plan, payment for these services is based on state- developed fee schedule rates, which are the same for both governmental and private providers. The agency's rates were set as of July 1, 2011 and are effective for services rendered on or after that date. The fee schedule is subject to annual/periodic adjustment. All rates, including current and prior rates, are published and maintained on the agency's website. Specifically, the fee schedule and any annual/periodic adjustments to the fee schedule are published at htto://www.dhhs.ne.gov/med/provhome.htm.

TN #, NE 11-20 . e120 Supersedes Approval paGEC 2: 201 ettectve Dats -

TN#. NE 10-10

DEPARTMENT OF HEALTH AND HUMAN SERVICES

FORM APPROVED OMB NO, 0938-0193

HEALTH CARE FINANCING ADMINISTRATION TRANSMITTAL AND NOTICE OF APPROVAL OF 1, TRANSMITTAL NUMBER: 2. STATE STATE PLAN MATERIAL 11-20 Nebraska

FOR: HEALTH CARE FINANCING ADMINISTRATION

3, PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID)

TO: REGIONAL ADMINISTRATOR HEALTH CARE FINANCING ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES

4, PROPOSED EFFECTIVE DATE duly 1, 201}

5. TYPE OF PLAN MATERIAL (Check One):

([] NEW STATE PLAN

(] AMENDMENT TO BE CONSIDERED AS NEW PLAN

bd AMENDMENT

COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment)

6. PEDERAL STATUTE/REGULATION CITATION:

7. FEDERAL BUDGET IMPACT: a FFY 2011 8( 68,755) b. FF¥ 2012 $(284,517)

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

Attachment 4.19-B, Item 9, page 5

9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (if Applicable):

Attachment 4.19-B, ltem 9, page 5

10. SUBJECT OF AMENDMENT;

Effective date of rates for Pediatric Feeding Disorder Clinic Intensive Day Treatment and Outpatient Treatment

11. GOVERNOR’S REVIEW (Check Ong}: (] GOVERNOR’S OFFICE REPORTED NO COMMENT (] COMMENTS OF GOVERNOR'S OFFICE ENCLOSED [-] NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

OTHER, AS SPECIFIED: Governor has waived review

12, SIGNATURE Lous STATE AGENCY OFFICIAL:

13, TYPED NAME: Vivianne M. Chaumont

14, TITLE: Director, Division of Medicaid and Long-Term Care

15. DATE SUBMITTED: September 22, 2011

16, RETURN TO:

Patricia (Pat) Taft

Division of Medicaid & Long-Term Care Nebraska Department of Heaith & Human Services 301 Centennial Mall South

Lincoln, NE 68509

FOR REGIONAL OFFICE USE ONLY

17, DATE RECEIVED: S epleaher..24, 9a!

18 DATE APPROVED: December 22, 201!

PLAN APPROVED -- ONE COPY ATTACHED

19, EFFECTIVE DATE OF APPROVED MATERIAL:

20. as i 1

Sly | Qo 21, TYPED NAME: 22, TITLE: Adkins Assoc pegi mel Admini strata —Limathy A. Weidler Medicaid and Children's Heath Qpelt’ on 23. REMARKS:

FORM HCKA-179 (07-92)

DEPARTMENT OF HEALTH & HUM ANSERVlCES Centers for Medicare & Medi<aid Services CAlIS 601 East 1 2'~ Stret't, Suite 355 Kansas City. Missouri 64106 Divisim> ofMOOicaid and O1i.Idren', Health OpeIalions March 7,2012 Vivianne Chaumont, Director Department of Health & Human Services Division of Medicaid and Long Term Care 301 Centennial Mall S., 5th Floor PO Box 95026 Lincoln, Nebraska 68509 Dear Ms. Chaumont: On August 12, 2011, the Centers for Medicare & Medicaid Services (CMS) received Nebraska's State Plan Amendment (SPA) transmittal #11-023, which proposes to reduce the fee schedule rates for outpatient hospital and lab services by 2. 5% with a proposed effective date of July 1,2011. This SPA 11-023 was approved on March 6, 2012, with an effective date of July 1, 2011 as requested by the State. Enclosed is a copy of the CMS-179 form, as well as, the approved page for incorporation into the Nebraska State Plan. If you have any questions regarding this amendment, please contact Narinder Singh at (816) 426-5925 or Narinder.Singh@cms.hhs.gov. Sinc~iL Jam s G. Scott ,-,,,,,,,,,,eiate Regional Administrator for Medicaid and Children's Health Operations Enclosure cc: Pat Taft

ATTACHMENT 3.1-A Item 2a, Page 1 Applies to both Categorically and Medically Needy STATE PLAN UNDER TITLE XIX OF THE SOCiAl SECURITY ACT State: Nebraska LIMITATIONS - OUTPATIENT HOSPITAl All psychiatric 1 ..~ng and ovalua1ions mus1 be performed by a licensed psychologist or under the 8up8Nlslon ot a IicenNd psychologist. TN No. NE 11-23 Approval Dale MAR 0 6 2012 E1!ective Date JUL 0 1 2011 Supersedes TN No. MS-OO-06

ATTACHMENT 3.1-A Item 2a, Page 3 Applies to both Categorically and Medically Needy STATE PlAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT Stat.: Nebraska LIMITATIONS - OUTPATIENT HOSPITAL SERVICES Abortions ... covenod when a physician oeM... that the pregnancy was a resun of rape or Incest, or the woman BUff... n,m a physical_er, injury or IIln...., including a I~.-endangerlng physical condition caused by or wing from the pregnancy Itself, that would place the woman In danger of death un Ie•• an abortion is performed. TN No. NE11-23 JUL 0 1 2011 Approval Dale MAR 0 6 2012 Effective Date ____ Supersedes TN No. MS=0M6

• ATIACHMENT 4.19-8 Item 2a, Page 1 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State Nebraska METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES Payment for OutpaUent Hospital and Emergency Room Services: For services provided on or after July 1, 2011, the Department pays for outpatient hospital and emergency services with a rate which is the product of: 1. Seventy three (73) percent of the cost-la-charges ralio from the hospital's latest Medicare cost report (Form CMS-2552-89, Pub. 15-11. WOrksheet C); multiplied by 2. The hospital's subm~ted charges on Form CMS-1450 (UB-04). The eHectrve date of the cosHo-charges percentage is the first day of the month folk>wing the Department's receipt of the cost report. Providers shall bill outpatient hospital and emergency room services on Form CMS-1450 (UB­ 04) in a summary bill fannat Providers shall not exceed their usual and customary charges to non-Medicaid patients when billing the Department. Exception: All outpatient clinical laboratory services must be itemized and identified with the appropriate HCPCS procedure codes. The Department pays for clinical laboratory services based on 97.5% of the fee schedule delermined by Medicare. Payment for Outpatient HospHal and Emergency Room ServiceS Provided by Critical Access Hospitals: Effective for cost reporting periods beginning after July 1, 2011. payment for outpatient services of a CAH is ninety seven point five percent (97,5%) of the reasonable cost of providing the services, as determined under applicable Medicare principles of reimbursement, except that the following principles do not apply: the lesser of costs or charges (LCC) rule and the reasonable compensation equivalent (RCE) limits for physician services to providers. NMAP will adjust interim payments to refted elimination of any fee schedule methods for specific services, such as laboratory or radiology services, that were previously paid for under those methods. Payment for these and other ou1patient services wiD be made in at ninety seven point five percent (97.5%) of the reasonable cost of providing the services. Professional servlces must be billed by the physician or practitioner using the appropriate physician/practitioner provider number, not the facility's provider number. To avoid any Interruption of payment, NMAP will retain and continue to bill under existing provider numbers until new CAH numbers are assigned. TN No. 11-23 IolAR 0 6 20\i'Effective Date 'JUL 0 1 2011 Supersedes Approval Date TN No. NE 1Q-14

ATTACHMENT 4.19-8 Item 2a, Page 2 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State Nebraska METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES Payment to Hospilal·Affiliated Ambulatory Surgical Centers: The Department pays for services provided in an HAASe according to Payment for Outpatient Hospital and Emergency Room Services, unless the HAASe is a Medicare-participating ambulatory surgical center (ASC). If the HAASe is a Medicare-participaling ASC, payment is made al the rate established by Medicaid for the appropriate group of procedures. Approval of Payment for Emergencv Room Services: AI least one of the foUowing condilions must be met before the Department approves payment for use of an emergency room: 1. The patient is evaluated or treated for a medical emergency, accident, or injury (see definition of medica; emergency in NAC 10·001 .02); 2. The patient's evaluation or treatment in the emergency room results In an approved inpatient hospital admission (the emergency room charges must be displayed on the inpatient claim as charges and included in the irlpatient per diem); or 3. The patient is referred by a physician such as for allergy shots or when traveling (a written referral by the physician must be attached 10 the claim); The facility should review emergency room services and determine whether services provided in the emergency room constitute an emergency and bill accordingly. When the facdity or the Department determine services are non-emergent, the room fee for non-emergent services provided in an emergency room will be disallowed 10 50 percent of the applicab(e ratio of cost-to-charges. All other Medicaid allowable charges incurred in this type visit will be paid at 73% of the ratio of cosHcrcharges. Diagnostic and Therapeutic Services: The paymenl rate for diagnostic and therapeutic services includes payment for services required to provide the saNtee. Extra charges, such as stat fees, caU~back fees, specimen handling fees, etc., are considered administrative expenses and are included in the payment rate. Payment to a New Hospnal for Outpatient Services: See the definition of a new operational facility in 471 NAC 1()..010.03A. Payment 10 a new hospital (a operational facility) will be made al 73% of the statewide average ratio of cost 10 charges for Nebraska hOSpitals as of July 1 of Ihal year as determined by the Department. This payment is retrospective for the firS1 reporting period for the facility. This ratio will be used until the Department receives the hospital's Initial cost report. The Department shall cost·settle claims for Medlcaid·covered services which are paid by the Department using 73% of the slatewide average ratio of cost to charges. The cost settlement will be the lower of cost or charges as reflected on the hosprtal's cost report (I.e., the Department's payment must not exceed the upper limit of the provider'S charges for services). TN No. 11-23 :JUL 0 1 2011 Effective Date _____ SUper>edes Approval Date TN No. NE 10-14

AnACHMENT 4.1 9-B Item 20, Page 3 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State Nebraska METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES Upon the Department's receipt of the hospital's initial Medicare cost report, lhe Department shall no longer consider the hospital to be a "n&oN hospital" for payment of outpatient services, The Department shall determine the rallo of cost to charges from the initial cost report and shall use that ratio to prospedively pay for outpatient services. (For a complete description of payment for outpatient servIces, see 471 NAC 1()..()1 0.06 ff.) Payment to An Out-of-State HospitaJ for Outpatient Services: Payment to an out-af-state hospital tor outpatient servtces will be made based on the statewide average ratio of cost to charges times 73% for all Nebraska hospt1als for that fiscal year as of July 1 of that year. Payment for Telebealth Services: Payment for telehealth services is set at the Medicaid rate for the compara~e In· person service. Payment for Telehealth Transmission.C.osts: Payment for telehealth transmission costs is set at the lower of: (1) the provider's submitted charge; or (2) the maximum allowable amount. The Department reimburses transmission costs for the line charges when directly related to a covered teleheaith service. The transmission must be in compliance with the quality standards for real time, two-way interactive audio-visual transmission as set forth in state regulations. as amended . TN No. 11-23 HAR 0 6 ?012 JUL 0 1 2011 Supersedes Approval Date _____ Effective Dale _____ TN No. NE 10-14

DEPAR'J'MBNT OF HEALTH AND HUMAH SERVICES FORM APPROVED HEALTH CAlU3 FINANClNG ADMIHi$TRATlON OMBNO.09~..oI93 TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: HEALTH CARE FINANCING ADMINlSTRAll0N TO: REGIONAL ADMJNIS1RATOR HEALTH CARE FINANCING ADMIN1STRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES I.1RANSMIITAL NUMBER: 11·23 2. STATE Nebraska 3. PROORAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) 4. PROPOSED EFFECTIVE DATE July 1,2011 S. TYPE OF PLAN MATERIAL IC""" 0..): OR ATTACHMENT (If AppJlcab/~): AttachmeDt 3']·A Item 21, pages t and 3 Attachment 4.19·B, Item 21, pages 1·3 Attachment 3.I-A ltem 2a, pages I and 3 Attldunent 4.19.B, Item 21, pages 1-3 a. FFY 2011 S (470,828) Outpatient Hospital Rate Reduction 8Ild Lab Fec Sc.hedule Reduction II. GOVERNOR'S REVIEW (Ch4d. On.): o GOVERNOR'S OFFICE REPORn:D NO COMMENT o OTHER, AS SPECIFIED: o COMMENTS OF GOVERNOR'S OFFICE ENCLOSED Governor has waived review o NO REPLY RECEIVED WITIIIN 45 DAYS OF SUBMITTAL =~;;~~~~~======~~~~========~ _'Ia(pat) Taft Division ofMcdicaid & Long-Term Care Nebraska Department ofHealth & Hwnan Sc:rvKe$ ''!<~~~11<"'&:!!''!!!.!~'-___-! 301 Centamial Mall South ~ Lincoln, NB 68!509 FORM RCFA·179 (07-92)

DEPARTMENT OF HEALTH & HUMAN SERVICES C/I. Ay Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12

ENTERS for MEDICARE & MEDICAID SERVICES Baltimore, Maryland 21244-1850 a

Center for Medicaid and CHIP Services

APR 18 2012

Vivianne M. Chaumont, Director

Division of Medicaid and Long-Term Care Nebraska Department of Health and Human Services 301 Centennial Mall South

Lincoln, Nebraska 68509

RE: Nebraska State Plan Amendment TN: 11-24

Dear Ms. Chaumont:

We have reviewed the proposed amendment to Attachment 4.19-D of your Medicaid State plan submitted under transmittal number (TN) 11-24. This amendment proposes a 2.5% rate reduction for nursing facility payment rates and provides that intermediate care facility for the mentally retarded (ICF/MR) payment will not receive an inflation adjustment. This amendment also removes obsolete language and adds clarifying language enabling the State plan to flow from year-to-year eliminating the need for certain annual updates.

We conducted our review of your submittal according to the statutory requirements at sections 1902(a)(13), 1902(a)(30), and 1903(a) of the Social Security Act and the implementing Federal regulations at 42 CFR 447 Subpart C. This is to inform you that Medicaid State plan amendment 11-24 is approved effective July 1, 2011. We are enclosing the HCFA-179 and the amended plan pages.

If you have any questions, please call Tim Weidler at (816) 426-6429. Sincerely,

Cindy Mann Director, CMCS

Enclosures

ATTACHMENT 4.19-D Page 1

12-011 Rates for Nursing Facility Servi 12-011.01 Purpose: This section:

1. Satisfies the requirements of the State Plan for Medical Assistance and 42 CFR 447.250 through 42 CFR 447.272;

2. Adopts rate setting procedures which recognize the required level and quality of care as prescribed by all governmental entities (including, but not limited to, federal, state and local entities);

3. Establishes effective accountability for the disbursement of Medical Assistance appropriations; and

4. ~ Provides for public notice of changes in the statewide method or level of payment pursuant to the requirements of Section 1902(a)(13) of the Social Security Act.

014 itions: The following definitions apply to the nursing facility rate determination system.

Allowable Cost means those facility costs which are included in the computation of the facility's per diem. The facility's reported costs may be reduced because they are not allowable under Medicaid or Medicare regulation, or because they are limited under 471 NAC 12-011.06.

Assisted Living Rates means standard rates, single occupancy, rural or urban, per day equivalent, paid under the Home and Community-Based Waiver Services for- Aged Persons or Aduits or Children with Disabilities (see 480 NAC 5).

Department means the Nebraska Department of Health and Human Services.

Division means the Division of Medicaid and Long-Term Care.

IHS Nursing Facility Provider means an Indian Health Services Nursing Facility or a

Tribal Nursing Facility designated as an IHS provider and funded by the Title I or ill of the Indian Self-Determination and Education Assistance Act (Public Law 93-638).

Level of Care means the classification of each resident based on his/her acuity level.

Median means a value or an average of two values in an ordered set of values, below and above which there is an equal number of values.

Nursing Facility means an institution (or a distinct part of an institution) which meets the definition and requirements of Title XIX of the Social Security Act, Section 1919.

Rate Determination means per diem rates calculated under provisions of 471 NAC 12- 011.08. These rates may differ from rates actually paid for nursing facility services for Levels of Care 101, 102, 103 and 104.

Supeeeae Approved _ APR 13 ale Effective JUL - 2 agit

TN# 10-19

ATTACHMENT 4.19-D Page 2

Rate Payment_ means per diem rates paid under provisions of 471 NAC 12-011.08. The payment rate for Levels of Care 101, 102, 103 and 104 is the applicable rate in effect for assisted living services under the Home and Community-Based Waiver Services for Aged Persons or Adults or Children with Disabilities (see 480 NAC 5).

Revisit Fees means fees charged to health care facllities by the Secretary of Health and Human Services to cover the costs incurred under Department of Health and Human Services, Centers for Medicare and Medicaid Services, Program Management’ for conducting revisit surveys on health care facilities cited for deficiencies during Initial certification, recertification or substantiated complaint surveys.

Urban means Douglas, Lancaster, Sarpy, and Washington Counties.

Waivered Facility means facilities for which the State Certification Agency has waived professional nurse staffing requirements of OBRA 87 are classified as "waivered" if the total number of waivered days exceeds 90 calendar days at any time during the reporting period.

Weighted Resident Days means a facility's inpatient days, as adjusted for the acuity level of the residents in that facility.

Other definitions which apply in this section are included in Nebraska Department of Health and Human Services Division of Public Health's regulations in Title 175, Chapter 12, Skilled Nursing Facilities, Nursing Facilities, and Intermediate Care Facilities and appropriate federal regulations governing Title XIX and Title XVIII.

42-011,03 General_ Information: Wherever applicable, the principles of reimbursement for providers cost and the related policies under which the Medicare extended care facliity program functions (Medicare's Provider Reimbursement Manual (HIM-15) updated by "Provider Reimbursement Manual Revisions” in effect as of July 1, 2009 are used in determining the cost for Nebraska nursing facilities with exceptions noted in this section. Chapter 15, Change of Ownership, of HIM-15 is excluded in its entirety.

That portion of a provider's allowable cost for the treatment of Medicaid patients is payable under the Nebraska Medica! Assistance Program (Medicaid) except as limited in this section. The aggregate payments by the Department do not exceed amounts which would be paid under Title XVHI principles of reimbursement for extended care facilities.

Except for IHS nursing facility providers, a provider with 1,000 or fewer Medicaid inpatient days during a complete fiscal year Report Period (see 471 NAC 12-011.088) will not file a cost report. The rate paid will be based on the average base rate components, effective July 1 of

the rate period of all other providers in the same care classification, following the initial desk audits.

42: Ilo : The following items are allowable costs under Medicaid.

meeting licensure and certification standards are those costs incurred in order to:

Meet the definition and requirements for a Nursing Facility of Title XIX of the Social Security Act, Section 1919;

TN# NE 114-24 . Supersedes Approved APR 18 2012 Effective JUL-i 2011 TN# 10-19

ATTACHMENT 4.19-D Page 10

12-011.06K Salaries of Administrators, Owners, and Directly Related Parties: Compensation received by an administrator, owner, or directly related party is limited to a reasonable amount for the documented services provided in a necessary function. Reasonable value of the documented services rendered by an administrator is determined from Medicare regulations and administrator salary surveys for the Kansas City Region, adjusted for inflation by the federal Department of Health and Human Services (see HIM-15, Section 905.6).

Beginning with the following Calendar year base numbers for 12/31/2010, the Administrator Compensation Maximum Amounts can be calculated based on the following methodology.

Beds Beds Beds Beds Beds Calendar Year HIM% 0-74 75-99 100-149 150-200 200+ 2010 1.5% 81,490 82,954 98,569 99,544 146,388

2011

To determine the Maximum Amount for State Fiscal Year 2011, for each bed category, add 1 to the Calendar Year 2010 HIM % and multiply this amount by 50% of the Calendar Year 2010 bed total. To this amount add 50% of the Calendar Year 2010 bed total. For future years update the Calendar Year information above (A) by replacing the HIM % with the updated HIM % from HIM 15 Section 905.6.

Example: —s- 1+. .015 X 40,745 = 41,356 41,356 + 40,745 = 82,101 Administrator Maximum Amounts for Cost Reports:

Beds Beds Beds Beds Beds State Fiscal Year 0-74 75-99 100-149 150-200 200+ 2011 82,101 83,576 99,308 100,291 147,486

2012

All compensation received by an administrator is included in the Administration Cost Category, unless an allocation has prior approval from the Department. Reasonable value of the documented services rendered by an owner or directly related party who hold positions other than administrator is determined by: (1) comparison to salaries paid for comparable position(s) within the specific facility, if applicable, or, if not applicable, then (2) comparison to salaries for comparable position(s) as published by the Department of Administrative Services, Division of State Personnel in the "State of Nebraska Salary Survey”.

12-011.061L_ Administration Expense: In computing the provider's allowable cost for determination of the rate, administration expense is limited to no more than 14 percent of the total otherwise allowable Direct Nursing and Support Services Components for the facility.

This computation is made by dividing the total allowable Direct Nursing and Support Services Components, less the administration cost category, by 0.86. The resulting quotient is the maximum allowable amount for the Direct Nursing and Support Services components, including the administration cost category. If a facility's actual allowable cost for the two

components exceeds this quotient, the excess amount is used to adjust the administration cost category.

Supersedes Approved Effective

TN# NE 11-24 APR 18 2012 JUL = 2.2011

TN# 10-19

ATTACHMENT 4.19-D Page 13

12-011.06P Other Limitations: Other limitations to specific cost components of the rate are included in the rate determination provision of this system.

12-011.07 (Reserved)

12-011,08 Rate Determination: The Department determines rates for facllities under the following cost-based prospective methodology.

42-011.08A Rate Period: The Rate Period is defined as July 1 through June 30. Rates paid during the Rate Period are determined (see 471 NAC 12011.08D) from cost reports submitted for the Report Period ending June 30 two years prior to the end of the Rate Perlod. For example, cost reports submitted for the Report Period ending June 30, 2009 determine rates for the Rate Period July 1, 2010 through June 30, 2011.

12-011,088 Report Period: Each facility must file a cost report each year for the reporting period of July 4 through June 30.

42-011.08C Care Classifications:. A portion of each individual facility's rate may be based on the urban or non-urban location of the facility.

12-011.08D Prospective Rates: Subject to the allowable, unallowable, and limitation provisions of 471 NAC 12-011.04, 12-011.05, and 12-011,06, the Department determines facility-specific prospective per diem rates (one rate corresponding to each level of care) based on the facility's allowable costs incurred and documented during the Report Period. The rates are based on financial, acuity, and statistical data submitted by facilities, and are subject to the Component maximums.

Component maximums are computed using audited data following the initial desk audits, and are not revised based on subsequent changes to the data. Only cost reports with, a full year’s data are used in the computation. Cost reports from providers entering or leaving Medicaid during the immediately preceding Report Period are not used In the computation.

-Each facility's prospective rates consist of three components:

14. The Direct Nursing Component adjusted by the inflation factor;

2. The Support Services Component adjusted by the inflation factor; and 3. The Fixed Cost Component. . The Direct Nursing Component and the Support Services Component are subject to maximum per diem payments based on Median/Maximum computations.

TN# NE 41-24 Supersedes Approved APR 18 2012 Effective JUL — 4 2011

TN# 10-19

ATTACHMENT 4.19-D Page 15

42-011.08D3 Fixed Gost Component: This component of the prospective rate is computed by dividing the facility's allowable interest, depreciation, amortization, fong-term rent/lease payments, personal property tax, real estate tax, and other fixed costs by the facility's total inpatient days (see 471 NAC 12-011.06B). Rate determination for the Fixed Cost Component for an individual facility is computed using the lower of its own per diem as computed above, or a maximum per diem of $27.00 excluding personal property and reai estate

taxes. 42-011.08D4 Inflation Factor: For the Rate Period of July 1, 2011 through June

30, 2012, the Inflation factor is negative 3.91%.

12-011.08E Exception Process, An individual facility may request, on an exception basis, the Director of the Division of Medicaid and Long-Term Care to consider specific facility circumstance(s), which warrant an exception to the facility's rate computed for its Fixed Cost Component. An exception may only be requested if the facility's total fixed costs (fotal costs, not per diem rate), as compared to the immediately prior report period, have increased by ten percent or more. In addition, the facility's request must Include:

4. Specific identification of the increased cost(s) that have caused the facility's total fixed costs to increase by 10 percent or more, with justification for the reasonableness and necessity of the increase;

2. Whether the cost increase(s) are an ongoing or a one-time occurrence in the cost of operating the facility; and

3. If applicable, preventive management action that was implemented to control past and future cause(s) of identified cost increase(s).

12-011.08F Rate Payment for Levels of Care 101, 102, 103 and 104: Rates as determined for Levels of Care 101, 102, 103 and 104 under the cost-based prospective methodology of 471 NAC 42-014.08A through 12-011.08E may be adjusted for actual payment. The payment rate for Levels of Care 101, 102, 103 and 104 is the applicable rate in effect for assisted living services under the Home and Community-Based Waiver Services for Aged Persons or Adults or Children with Disabilities (see 480 NAC 5). .

42-011.08G Out-of-State Facillties. The Department pays out-of-state facilities participating in Medicaid at a rate established by that state's Medicaid program at the time of the issuance or reissuance of the provider agreements. The payment is not subject to any type of adjustment.

Supersedes Approved Effective TN# 10-19

TN NE-11-24 APR 18 2012 JUL - 12011

ATTACHMENT 4.19-D Page 16

12. 08H R: New Providers:

Definition: A provider is any individual or entity which fumishes Medicaid goods or services under an approved provider agreement with the Department. A new provider is an individual or entity which obtains their initial, facility-specific provider agreement to operate an existing nursing facility due to a change in ownership, or to operate a nursing facility not previously enrolled in Medicaid. For purposes of this definition, "nursing facility" means the business operation, not the physical property. A “new provider’ retains that status until the start of the prospective Rate Period corresponding to the provider's first, full twelve-month Report Period.

Example A: A new provider enters the Medicaid program on May 7, 2007. Their first full twelve- month Report Period is for the period ending June 30, 2008, which corresponds to the prospective Rate Period beginning July 1, 2009. They are a “new provider" from May 7, 2007 through June 30, 2009. .

Example B; A new provider enters the Medicaid program on duly 1, 2007. Their first full, twelve-month Report Period is for the period ending June 30, 2008, which corresponds to the prospective Rate Period beginning July 1, 2009. They are a ‘new provider” from July1, 2007 through June 30, 2009.

Definition: The “Report Period” for a fiscal year determines rates, or interim rates, for a “prospective Rate Period” two years after the Report Period, For example, Report Period 2006- 2007 determines prospective rates, or interim rates, for the 2008-2009 Rate Period.

A. Medicaid rates for new providers, except for IHS nursing facility providers are determined as follows:

14. New providers entering the Medicaid program as a result of a change of ownership:

For the Rate Period beginning on the purchase date through the following June 30, new providers entering the Medicaid program as a result of a change of ownership receive interim Medicaid rates equal to the rates of the selier in effect on the purchase date, subject to maximums and limitations applicable to the Rate Period. The interim rates are retroactively settled based on the facility's audited Medicaid cost report for the Report Period beginning on the purchase date through the following June 30, subject to maximums and limitations applicable to the Rate Period. Providers with 1,000 or fewer annualized Medicaid days during a Report Period do not file a cost report and are not subject to a retro-settlement of their rates.

For the following July 1 through June 30 Rate Period, new providers receive interim tates computed from the seller's audited cost report for the corresponding Report Period, subject to maximums and limitations applicable to the Rate Period. The interim rates are retroactively settled based on the facility's audited Medicaid cost report for the same July 1 through June 30 Report Period, subject to maximums and limitations applicable to the Rate Period. Providers with 1,000 or fewer annualized Medicaid days during a report period do not file a cost report and are not subject to a retro-settlement of their rates.

TN# NE 11-24

JUL - 22011

Supersedes Approved TN# 10-19

APRI8202 caine

ATTACHMENT 4.19-D Page 16a

If applicable, for the next July 1 through June 30 Rate Period, new providers receive interim Medicaid rates computed from their initial part-year, audited Medicaid cost report for the Report Period beginning on the purchase date and ending the following June 30, subject to maximums and limitations applicable to the Rate Period. The interim rates are retroactively settled based on the facility's audited Medicaid cost report for the same July 1 through June 30 Report Period, subject to maximums and limitations applicable to the Rate Period. Providers with 1,000 or fewer annualized Medicaid days during a report period do not file a cost report and are not subject to a retro-settlement of their rates.

When “new provider” status no longer applies, rates are computed under 471 NAC 42-011.08D Prospective Rates.

2. New providers entering the Medicaid program to operate a nursing facility not previously enrolled in Medicaid:

For the Rate Period beginning on the Medicaid certification date through the following June 30, new providers entering the Medicaid program to operate a nursing facility not previously enrolled in Medicaid receive interim Medicaid rates based on the average base rate components effective at the beginning of the Rate Period of all other providers in the same Care Classification, The interim rates are retroactively settled based on the facility's audited Medicaid cost report for the Report Period beginning on the Medicaid certification date and ending on the following June 30, subject to maximums and limitations applicable to the Rate Period. Providers with 4,000 or fewer annualized Medicaid days during a Report Period do not file a cost report and are not subject to a retro-settlement of their rates.

For the following July 1 through June 30 Rate Period, new providers receive initial interim rates based on the average base rate components effective at the beginning of the Rate Period of all other providers in the same Care Classification, computed using audited data following the initial desk audits. The initial interim rates are revised based on the provider's audited Medicaid cost report for their first Report Period, subject to maximums and limitations ‘applicable to the Rate Period. The revised interim rates will be issued within ten days of the completion of the initial desk audit of the facility’s cost report. The revised interim rates are retroactively settled based on the facility's audited Medicaid cost report for the same July 1 through June 30 Report Period, subject to maximums and limitations applicable to the Rate Period. Providers with 1,000 or fewer annualized Medicaid days during a report period do not file a cost report and are not subject fo a retro-settlement of their rates.

if applicable, for the next July 1 through June 30 Rate Pericd, new providers will receive interim Medicaid rates computed from their initial part-year, audited Medicaid cost report for the Report Period beginning on the Medicaid certification date and ending the following June 30, subject to maximums and limitations applicable to the Rate Period. The interim rates are retroactively settled based on the facility's audited Medicaid cost report for the same July 1 through June 30 Report Period, subject to maximums and limitations applicable to the Rate Period.

‘TN# NE 11-24 . Maden approves _APRI8 202 rgctve JUL - 12011

TN# New page

ATTACHMENT 4.19-D Page 16b

Providers with 1,000 or fewer annualized Medicaid days during @ report period do not file a cost report and are not subject to a retro-settlement of their rates.

When “new provider” status no longer applies, rates are computed under 471 NAC 12-011.08D Prospective Rates.

B. Medicaid rates for new IHS nursing facility providers are determined as follows:

1. New providers entering the Medicaid program as a result of a. change of ownership: For the Rate Period beginning on the purchase date through the following June 30, ‘new providers entering the Medicaid program as a result of a change of ownership receive Medicaid rates equal to the rates of the seller in effect on the purchase date, subject to maximums and limitations applicable to the Rate Period.

For the following July 1 through June 30 Rate Period, new providers receive rates computed from the seller's audited cost report for the corresponding Report Period, subject to maximums and limitations applicable to the Rate Period. :

If applicable, for the next July 1 through June 30 Rate Period, new providers receive Medicaid rates computed from their initial part-year, audited Medicaid cost report for the Report Period beginning on the purchase date and ending the following June 30, subject to maximums and limitations applicable to the Rate Period.

When “new provider’ status no longer applies, rates are computed under 471 NAC 12-011.08D Prospective Rates. :

2. New providers entering the Medicaid program to operate a nursing facility not previously enrolled in Medicaid:

For the Rate Period beginning on the Medicaid certification date through the following June 30, new providers entering the Medicaid program to operate a nursing facility not previously enrolled in Medicaid receive Medicaid rates based on the average base rate components effective at the beginning of the Rafe Period of all other providers in the same Care Classification.

For the following July 1 through June 30 Rate Period, new providers receive rates based on the average base rate components effective at the beginning of the Rate Period of ali other providers in the same Care Classification, computed using audited data following the initial desk audits.

If applicable, for the next July 1 through June 30 Rate Period, new providers will receive Medicaid rates computed from their initial part-year, audited Medicaid cost report for the Report Period beginning on the Medicaid certification date and ending

the following June 30, subject to maximums and limitations applicable to the Rate enod.

When “new provider’ status no longer applies, rates are computed under 471 NAC 12-011.08D Prospective Rates.

Supeedes - approved APR18 202 cteoive __ JUL ~ 2 2011

ATTACHMENT 4.19-D Page 17

42-011,08J Providers Leaving the NMAP: Providers leaving the NMAP as a result of change of ownership or exit from the program shall comply with provisions of 471 NAC 12-011.10, Reporting Requirement and Record Retention.

TNANE(24 ved APR1S 2 — epectne _ JUL ~ 1.2011

TN# 10-19

412-0 their

ATTACHMENT 4.19-D Page 18

42-011,08K Special Funding Provisions for Governmental Facilities: City or county- owned facllities are eligible to participate in the following transactions to increase reimbursement. The transaction is subject to the payment limits of 42 CFR 447,272 {payments may not exceed the amount that can reasonable be estimated to be paid under Medicare payment principles), City or county owned refers to the common meaning of ownership of the physical structure(s); the governmental entity may or may not be directly involved in the dally operation of the facility. .

1. City or county-owned facilities with a 40% or more Medicaid mix of inpatient days are eligible to receive the Federal Financial Participation share of allowable costs exceeding the applicable maximums for the Direct Nursing and the Support Services Components, This amount is computed after desk audit and determination of final rates for a Report Period by multiplying the current NMAP Federal Financial Participation percentage by the facility's allowable costs above the respective maximum for the Direct Nursing and the Support Services Components. Verification of the eligibility of the expenditures for FFP is accomplished during the audit process.

42-011,08L Special Funding Provisions for IHS Nursing Facility Providers: IHS nursing facility providers are eligible to receive the Federal Financial Participation share of allowable costs exceeding the rates paid for the Direct Nursing, Support Services and Fixed Cost Components for all Medicaid residents who are IHS eligible. This amount is computed after desk audit and determination of allowable costs for a Report Period. The amount is calculated as the NMAP Federal Financial Participation percentage times the difference between allowable costs for all Medicaid IHS eligible residents and the total amount paid for all Medicaid INS eligible residents, if greater than zero.

12-011,08M (Reserved)

Depreciation: This subsection replaces Medicare regulations on depreciation in entirety, except that provisions concerning sale-leaseback and lease-purchase

agreements (Medicare's Provider Reimbursement Manual (HIM-15), Section 110) are retained, subject to the following Medicaid depreciation regulations.

Tl 2: . TN#NE 1124 poproved __APRI8202 —eftectve __ JUL ~ 1.2011

TN# 10-19

ATTACHMENT 4.19-D Page 25

Facilities which provide any services other than certified nursing facility services must report costs separately, based on separate cost center records. As an alternative to separate cost center records and for shared costs, the provider may use a reasonable allocation basis documented with the appropriate statistics. All allocation. bases must be approved by the Department before the report period. A Medicare certified facility must not report costs for a level of care to the Department which have been reported for a different level of care ona Medicare cost report.

12-011.10A Disclosure of Cost Reports: Cost reports for all report periods ending October 30, 1990, or thereafter, are available for public inspection by making a written request to the Department of Health and Human Services, Division of Medicaid and Long-Term Care, Audit. The request must include the name (inctuding an individual to contact), address, and telephone number of the individual or organization making the request; the nursing facility name, location, and report period for the cost report requested; and directions for handling the request (review the reports at the Department's Lincoln State Office Building address; pick up copies at that office; or mail copies). The total fee, based on current Department policy

.dhhs.ni ipolicies/PublicRecords. must be paid. in advance. The nursing facility will receive a copy of a request to inspect its cost report.

12-011.11 Audits: The Department will perform at least one initial desk audit and may perform subsequent desk audits and/or a periodic field audit of each cost report. Selection cf subsequent desk audits and field audits will be made as determined necessary by the Department to maintain the integrity of the Nebraska Medical Assistance Program. The Department may retain an outside Independent public accounting firm, licensed to do business in Nebraska or the state where the financial records are maintained, to perform the audits. Audit reports must be completed on all field audits and desk audits. All audit reports will be retained by the Department for at least three years following the completion and finalization of the audit.

An initial desk audit will be completed on all cost reports. Care classification maximums and average base rate components are computed using audited data following the end of the Cost Report Period. Subsequent desk and field audits will not result in a revision of care classification maximums or average base rate components.

All cost reports, including those previously desk audited but excluding those previously field audited, are subject to subsequent desk audits. The primary period(s) and subject(s) to be desk-audited are indicated in a notification letter sent to the provider to initiate a subsequent desk audit. The provider must deliver copies of schedules, summaries, or other records requested by the Department as part of any desk audit.

TN #. NE 11- . INA NET veg _APRES I oie tUL- 2000 TN #. 10-19 os

ATTACHMENT 4.19-D Page 27

12-011,13 Penalties: Under federal law, the penalty for making a false statement or misrepresentation of a material fact in any application for Medicaid payments and for soliciting, offering, or accepting kickbacks or bribes (including the rebate of a portion of a fee or charge for a patient referral) is imprisonment up to five years, a fine of $25,000, or both. Similarly, making a false statement of material fact about conditions or operations of any institution is a felony punishable by up to five years imprisonment, a fine of not more than $25,000, or both.

42-011.14 Appeal Process: Final administrative decision or inaction in the allowable cost determination process is subject to administrative appeal. The provider may request an appeal in writing from the Director of the Division of Medicaid and Long-Term Care within 80 days of the decision or inaction. The request for an appeal must include identification of the specific adjustments or determinations being appealed and basis or explanation of each item, or both. See 471 NAC 2-003 and 465 NAG 2-006 for guidelines for appeals and fair hearings.

After the Director of the Division of Medicaid and Long-Term Care issues a determination in regard to the administrative appeal, the Department will notify the facility of the final settlement amount. Repayment of the settlement amount must be made within 30 days of the date of the letter of notification.

TN #. NE 14-24 APR 13 2012 JUL ~ 2 2011

Supersedes Approved Effective TN #. 10-19

ATTACHMENT 4.19-D Page 28

12-011.15 Administrative Finality: Administrative decision or inaction in the allowable cost determination process for any provider, which is otherwise final, may be reopened by the Department within three years of the date of notice of the decision or inaction.

"Reopening" means .an action taken by the Director of the Division of Medicaid and Long- Term Care to reexamine or question the correctness of a determination or decision which is otherwise final. The Director is the sole authority in deciding whether to reopen. The action may be taken:

4. On the initiative of the Department within the three-year period;

2. _ In response to a written request from a provider or other entity within the three-year period. Whether the Director of the Division of Medicaid and Long-Term Care will reopen a determination, which is otherwise final, depends on whether new and material evidence has been submitted, a clear and obvious error has been made, or the determination is found to be inconsistent with the law, regulations and rulings, or general instructions; or

3. Anytime fraud or abuse is suspected.

TN #. NE 11-24 APR 18 2012 JUL - 22011 Supersedes Approved Effective TN#. 10-19 —_——

ATTACHMENT 4.19-D Page 31

For each reporting period, the total resident days (per the MDS system) at each care level are multiplied by the corresponding weight (see 471 NAC 12-013.04). The resulting products are summed to determine the total weighted resident days per the MDS system. This total is then divided by the MDS total resident days per the MDS system. This total is then divided by the MDS total resident days and multiplied by total resident days per the facility's Nebraska Medicaid Cost Report to determine the total number of

Weighted Resident Days for the facility, which is the divisor for the Direct Nursing Component.

12-013,03 Resident Level of Care Weights: The following weighting factors shall be assigned to each resident level of care, based on the CMS RUG III 5.20 version:

Level of Casemix Casemix Index Casemix Index Care Index Value Description Value 163 RAD Rehabilitation/ADL = 17-18 1.66 162 RAC Rehabilitation/ADL = 14-16 1.31 161 RAB Rehabilitation/ADL = 9-13 1.24 160 RAA Rehabilitation/ADL = 4-8 1.07 172 SE3 Extensive Services 3/ADL >6 2.10 171 SE2 Extensive Services 2/ADL >6 1.78 170 SE1 Extensive Services 1/ADL >6 1,54 152 ssc Special Care/ADL = 17-18 11.44 151 SSB Special Care/ADL = 15-16 1.33 150 SSZ Special Care/ADL = 4-14 1.28 145 cc2 Clinically Complex w/Depression/ADL. = 17-18 1.42 144 cc1 Clinically Complex/ADL = 17-18 1.25 143 CB2 Clinically Complex w/ Depression/ADL = 12-16 1,15 142 CB1 Clinically Complex/ADL = 12-16 1.07 141 CA2 Clinically Complex w/Depression/ADL = 4-11 1.06 140 CA1 Clinically Complex/ADL = 4-11 0.95 133 1B2 Cognitive Impairment with Nursing Rehab/ADL= 6-10 0.88 132 1B1 Cognitive Impairment/ADL = 6-10 0.85 131 1A2 Cognitive Impairment with Nursing Rehab/ADL = 4-5 0.72 130 1A1 Cognitive ImpairmentADL = 4-5 0.67 123 BB2 Behavior Prob w/Nursing Rehab/ADL = 6-10 0.86 122 BB1 Behavior Prob/ADL = 6-10 0.82 121 BA2 Behavior Prob w/Nursing Rehab/ADL = 4-5 0.71 120 BA1 Behavior Prob/ADL = 4-5 0.60 115 PE2 Physical Function wiNursing Rehab/ADL = 16-18 1.00 114° «~PE1 Physical Function/ADL = 16-18 0.97 113 PD2 Physical Function w/Nursing Rehab/ADL = 11-15 0.91 112 PD1 Physical Function/ADL = 11-15 0.89 111 PC2 Physical Function w/Nursing Rehab/ADL = 9-10 0.83 110 PC1 Physical Function/ADL = 9-10 ; 0.81 Medicaid Waiver Assisted Living Levels of Care 104 PB2 Physical Function w/Nursing Rehab/ADL = 6-8 0.65 103 PB1 Physical Function/ADL = 6-8 0.63 102 PAZ Physical Function w/Nursing Rehab/ADL = 4-5 0.62 101 PA1 Physical Furiction/ADL = 4-5 0.59 Default Rate — Used When No Assessment is Available

180° STS Short Term Stay * 0.59

TN #. NE 11-24

Supersedes Approved APR 18 2012 Effective JUL — 2 2011

TN #. 10-19 .

ATTACHMENT 4.19-D Page 32

*Level of Cara 180 (Short-term stay) is used for stays of less than 14 days when a client Is discharged and the facility does not complete a full MDS admission assessment of the client. This is effective for admissions on or after July 1, 2010.

12-013.04 Verification; Resident assessment information is audited as a procedure in the Department of Health and Human Services Division of Public Health, Survey and

Certification process. TN #. NE 11-24 APR 18 200 JUL - 12011 Supersedes Approved Effective 0

TN #, 14-11

ATTACHMENT 4.19-D Page 45

The facility must submit Form FA-66, "Long Term Care Cost Report," to the Department for each fiscal year ending June 30. Medicare cost reporting forms may be substituted when Form FA-66 is not otherwise required fo be submitted. Form FA-66 must be completed in accordance with 471 NAC 12-012, Completion of Form FA-66, "Long Term Care Cost Report," and 471 NAC 12-011 ff., Rates for Nursing Facility Services, as applicable. Medicare cost reports must be completed in accordance with Medicare's Provider Reimbursement Manual (HIM- 15). If the facility provides both nursing facility services and special needs services, direct accounting and/or cost allocations necessary to distribute costs between the nursing facility and the special needs unit must be approved by the Department of Health and Human Services, Long Term Care Audit Unit.

The Department shall compute the allowable cost per day from the most recent State fiscal year Form’ FA-66 or the most recent Medicare cost report, as applicable, which will be the basis from which a prospective rate is negotiated. Payment for fixed costs is limited to the lower of the individual facility's fixed cost per diem or a maximum per diem of $54.00 excluding personal property and real estate taxes. Negotiations may include, but are not limited to, discussion of appropriate inflation/deflation expectations for the rate period and significant increases/decreases in the cost of providing services that are not reflected in the applicable cost report. The cost of services generally included in the allowable per diem include, but are not limited to:

a. Room and board;

b. Preadmission and admission assessments,

c. All direct and indirect nursing services;

d. All nursing supplies, fo include trach tube and related trach care supplies, catheters, etc.;

e. All routine equipment, to include suction machine, IV poles, etc.;

f. Oxygen and related supplies;

g. Psychosocial services;

h. Therapeutic recreational services;

i. Administrative costs;

j.. Plant operations;

k. Laundry and linen supplies;

1. Dietary services, to include tube feeding supplies and pumps;

m. Housekeeping; and

n. Medical records.

TN #. NE 14-24

Supersedes

Approval Date APR 18 2012 nective Date JUL = 2 2011

TN#. MS-08-06

ATTACHMENT 4.19-D Page 53

31- ayment for ICF/MR Services 31-008.01 Purpose: This section:

14. Satisfies the requirements of the State Plan for Medical Assistance and 42 CFR 447, Subpart C, which provide for payment of ICF/MR services;

2. Adopts rate setting procedures which recognize the required level and quality of care as prescribed by all governmental entities (including, but not limited to, federal, state, and focal entities);

3. Establishes effective accountability for the disbursement of Medical Assistance appropriations; and

4. Provides for public notice of changes in the statewide method or level of payment pursuant to the requirements of Section 1902(a)(13) of the Social Security Act.

31-008,02 General Information: Wherever applicable, the principles of reimbursement for provider's cost and the related policies under which the Medicare extended care facllity program functions (Medicare's Provider Reimbursement Manual (HIM-15) updated by "Provider Reimbursement Manual Revisions" in effect as July 1, 2009) are used in determining the cost for Nebraska ICF/MRs with exceptions noted in this section. Chapter 15, Change of Ownership, of HIM-15 is excluded In its entirety.

That portion of a provider's allowable cost for the treatment of Medicaid patients is payable under the Nebraska Medical Assistance Program (Medicaid) except as limited in this section. The aggregate payments by the Department do not exceed amounts which would be paid under Title XVIII principles of reimbursement for extended care facilities.

31-008.03 Allowable Costs: The following items are allowable costs under Medicaid.

31-008,03A Cost of Meeting Licensure and Certification Standards: Allowable costs for meeting licensure and certification standards are those costs incurred in order to:

4. Meet the definition in 42 CFR 440.150;

2. Comply with the standards prescribed by the Secretary of Health and Human Services (HHS) in 42 CFR 442;

3. Comply with requirements established by the Nebraska Department of Health and Human Services, Division of Public Health, the agency responsible for establishing and maintaining health standards, under 42 CFR 431.610; and

4. Comply with any other state law licensing requirements necessary for providing skilled nursing or intermediate care facility, as applicable.

31-008.03B Items Included in Per Diem Rates: The following items are included in the per diem rate:

TNi# NE11-24 APR 18 2012 Supersedes Approved Effective JUL. 1 200i TN# 10-19

ATTACHMENT 4.19-D Page 61

31-008,05K Certificate of Need Approved Projects: Notwithstanding any other provision of 471 NAC 31-008, the fixed costs reported to the Department for a Division of Public Health Certificate of Need reviewed project must not exceed the amount that would result from the application of the approved project provisions including the estimated interest rates and asset lives.

Certificate of Need provisions recognized by’ the Department, for the purposes of rate setting, is the original project as approved, the approved project amendments submitted within 90 days of the transfer of ownership or opening of newly constructed areas, and the allowable cost overruns disclosed in a final project report submitted to the Division of Public Health within 180 days of the opening of newly constructed areas. Project amendments and project reports submitted to the Division of Public Health Certificate of Need after the periods defined above will be recognized upon approval beginning on the date that the amendment or report is received by the Division of Public Health. The added costs incurred before the date the late amendment or report is filed will not be recognized retroactively for rate setting.

ICF/MRs with 4-15 beds are excluded from Certificate of Need requirements.

31-008.05L_ Salaries _of Administrators, Owners, and Directly Related Parties: Compensation received by an administrator, owner, or directly related party is limited to a reasonable amount for the documented services provided in a necessary function. Reasonable value of the documented services rendered by an administrator is determined from Medicare regulations and administrator salary surveys for the Kansas City Region, adjusted for inflation by the federal Department of Health and Human Services (see HIM-15, Section 905.6). See 12-011.06K for Administrator compensation maximum amounts.

All compensation received by an administrator is included in the Administration Cost Category, unless an allocation has prior approval from the Department. Reasonable value of the documented services rendered by an owner or directly related party who hold positions other than administrator is determined by: (1) comparison to salaries paid for comparable position(s) within the specific facility, if applicable, or, if not applicable, then (2) comparison to salaries for comparable position(s) as published by the Department of Administrative Services, Division of State Personnel in the "State of Nebraska Salary Survey”.

31-008.05M_ Administration Expense: In computing the provider's allowable cost for determination of the rate, administration expense is limited to no more than 14 percent of the total otherwise Personnel Operating and Non-Personnel Operating Cost Componenis for the facility. ra ; .

Supersedes Approved

TN# NE11-24 APRS 2012 effective YUL ~ 4 2011 TN# 10-19 |

ATTACHMENT 4.19-D Page 62

’ This computation is made by dividing the total allowable Personnel Operating and Non- Personnel Operating Cost Components, less the administration cost category, by 0.86. The resulting quotient is the maximum allowable amount for the Personnel Operating and Non-Personnel Operating Cost components, including the administration cost category. If a facility's actual allowable cost for the two components exceeds this quotient, the excess amount is used to adjust the administration cost category.

31-008.05N Facility Bed Size Exception: Rates for any privately-owned ICF/MR with less than 16 beds that received Medicaid reimbursement prior to July 1, 2009 will be determined based on the methodology described in 471 NAC 31-008.08C for ICF/MRs with 16 or more beds.

31 Other Limi is; Other limitations to specific cost components of the rate are included in the rate determination provision of this system.

31-008,08 Rate Determination: The Department determines rates under the following guidelines:

31-008.06A Rate Period: The Rate Period for non-State-operated ICF/MR providers is defined as July 1 through June 30. Rates paid during the Rate Period are determined from cost reports submitted for the Report Period ending June 30. two years prior to the end of the Rate Period (see 471 NAC 31-008.06C1). For example, cost reports submitted for the Report Period ending June 30, 2009 determine rates for the Rate Period July 1, 2010 through June 30, 2011.

The Rate Period for State-Operated ICF/MR providers is defined as July 1 through June 30..

31:008.06B Report Period: Each facility must file a cost report each year for the reporting period ending June 30.

1-008. for Intermediate Care Facili r_th I arded_(ICF/M Excludi O} CE/MR iders:

31 1_ICF/MR: 18 b 4

Subject to the allowable, unallowable, and limitation provisions of this system, the Department determines facility-specific prospective per diem rates based on the facility's allowable, reasonable and adequate costs incurred and documented during the Report Period. The rates are based on financial and Statistical data submitted by the facilities. Individual facility prospective rates have five components:

4. we ICF/MR Personnel Operating Cost Component adjusted by the inflation ctor;

The ICF/MR Non-Personnel Operating Cost Component adjusted by the inflation factor;

The ICF/MR Fixed Cost Component;

The ICF/MR Ancillary Cost Component adjusted by the inflation factor, and The ICF/MR Revenue Tax Cost Component.

Aho NV

Sd Approved APR18 202 crective JUL — 1.2011

TN# 10-19

ATTACHMENT 4.19-D Page 67

31-008.06C4b ICF/MRs with 4-15 beds:

The Non-Personnel Operating Cost Component of the Final Rate is the allowable non-personnel operating cost per day as computed for the ICF/MR provider's most recent cost report period.

31-008,08C5 ICF/MR Fixed Cost Component: This component includes the interest, depreciation, amortization, long-term rent/llease payments, personal property tax, real estate tax, gross revenue tax, and other fixed costs. The fixed cost component is the allowable fixed cost per day as computed for the facility's most recent cost report period.

31-008,06C8 ICF/MR Ancillary Cost Component: The ancillary cost component of the rate is the allowable ancillary cost per day as computed for the facility's most recent report period.

31-008.06C7_ICF/MR Inflation Factor. For the Rate Period of July 1, 2011 through June 30, 2012, the inflation factor is O%.

31-0 ICF/MR Revenue Tax 08.06C8a | i or 8

Under the {CF/MR Reimbursement Protection Act, the iCF/MR revenue tax per diem is computed as the prior report period net revenue divided by the prior report period facility resident days. (See 405 NAC 1-003.).The Tax Cost Component shall be prorated when the revenue tax is based on less than a full fiscal year’s data.

31-008.06C8b ICF/MRs with 4-15 beds:

‘Under the ICF/MR Reimbursement Protection Act, the ICF/MR revenue tax per diem is computed as the prior report period net revenue times the applicable tax percentage(s) divided by the prior report period facility resident days. (See 405 NAC 1-003.). The Tax Cost Component shall be prorated when the revenue tax is based on less than a full year’s data.

31-008.06C9 ICE/MR Exception Process: An individual facility may request, on an exception basis, the Director of the Division of Medicaid and Long-Term Care to consider specific facility circumstance(s), which warrant an exception to the facility's rate computed for its Fixed Cost Component. An exception may only be requested if the facility's total fixed costs (total costs, not per diem rate), as compared to the immediately prior report period, have increased by ten percent or more, In addition, the facility's request must include: 1. Specific identification of the increased cost(s) that have caused the facility's total fixed costs to increase by 10 percent or more, with justification for the reasonableness and necessity of the increase;

2. Whether the cost increase(s) are an ongoing or a one-time occurrence in the

cost of operating the facility; and

3. If applicable, preventive management action that was implemented to control

past and future cause(s) of identified cost increases(s}.

TN# NE 11-24 APR 18 2012

Supersedes TN# 40-19

Approved Effective JUL - 2 2014

ATTACHMENT 4.19-D Page 69

31-008.06D4_Non-Personnel_ Operating _Cost Component; This component includes all costs other than salaries, fringe benefits, the personnel cost portion of purchased services, and the personnel cost portion of management fees or allocated expenses for the administrative, dietary, housekeeping, laundry, plant related, and social service cost centers. The Non-Personne! Operating Cost Component of the Final Rate Is the allowable non-personnel operating cost per day as computed for the ICF/MR provider's most recent cost report period.

31-008.08D5 Fixed Cost Component: This component includes the interest, depreciation, amortization, long-term rent/lease payments, personal property tax, real estate tax, and other fixed costs. The Fixed Cost Component of the Final Rate Is the allowable fixed cast per day as computed for the ICF/MR provider's most recent cost report period.

31-008,06D8_ICF/MR Revenue Tax Cost. Component; Under the ICF/MR Reimbursement Protection Act, the ICF/MR revenue tax per diem is computed as the prior report period net revenue divided by the prior report period facility resident days. (See 405 NAC 1-003.). The Tax Cost Component shall be

prorated when the revenue tax is based on less than a full fiscal year’s data.

31-008.08E Out-of-State Facilities. The Department pays out-of-state facilities participating in Medicaid at a rate established by that state's Medicaid program at the time of the issuance or reissuance of the provider agreement. The rate will not exceed the average per diem being paid to Nebraska non-State-operated facilities for services in a similar care classification. The payment is not subject to any type of adjustment. -

31-008.08F Initial Rates for New Providers:

31-008,06F1 Initial Rates for New Providers of ICF/MRs with 16 beds or more: Providers entering Medicaid as a result of a change of Ownership-will receive rates as follows. The rate in effect at the tirie of the charige in ownership will be paid to the new provider for the remainder of the rate period. For the next rate period, the cost reports. for all owners during the report period will bé combined. The combined report will be the complete cost report for that facility and'will be used for rate determinations and limitation'deferminations. 6 ' ’

Providers entering Medicaid as a result of new construction, a facility re-opening, or a certification change from Nursing Facility to ICF/MR will receive a prospective rate equal to the average prospective rate of all Nebraska non-State- operated facilities of the same care classification. The rate will change at the beginning of a new rate period. The rate will be based on the care class average until the provider's first rate period following participation in the program for one full report period. .

Supersedes TN# 10-19

TN NE 11-24 pr 820%

sepa execne JUL 2201

ATTACHMENT 4.19-D Page 76

Facilities that provide any services other than certified ICF/MR services must report costs separately, based on separate cost center records. As an alternative to separate cost center records and for shared costs, the provider may use a reasonable allocation basis documented with the appropriate statistics. All allocation bases must be approved by the Department before the report period. Any Medicare certified facility must not report costs for a level of care to the Department which have been reported for a different level of care on a Medicare cost report.

31-008.08A Disclosure of Cost Reports: Cost reports for all report periods ending October 30, 1990, or thereafter, are available for public inspection by making a written request to the Department of Health and Human Services Audit Unit. The request must include the name (including an individual to contact), address, and telephone number of the individual or organization making the request, the ICF/MR name, location, and report period for the cost report requested; and directions for handling the request (review the reports at the Department's Lincoln State Office Bullding address; pick up copies from the Department; or mail copies). The total fee, based on current Department policy (http/éwww2.dhhs.ne.qov/policies/PublicRecords.odf) must be paid in advance. The ICFIMR will receive a copy of a request to inspect its cost report.

31-008.08B Descriptions of Form FA-66, "Long-Term Care Gost Report": All providers participating in Medicaid must complete Form FA-66, consisting of Schedules “General Data," A (Parts 1 and 2), B (Parts 1, 2, 3, and 4), B-1, B-2, B-3, B-4, B-5, C, D, (Parts 1, 2, and 3), D-1, E (Parts 1 and 2), E-1, .F (Parts 1.and 2) and "Certification by Officer, Owner, or Administrator." (See 471-000-41 and 471-000-42 for an example of all schedules.) For FA-66 must be completed in accordance with regulations found at 471 NAC 12-012. Form FA-66 contains the following schedules, as described:

1. General Data: This schedule provides general information concerning the provider and its financial records.

2. Schedule A, Occupancy Data: This schedule summarizes the licensed capacity and Inpatient days for all levels of care.

Part 1 identifies the certified days available, and Part 2 identifies the inpatient census data of the facility. This data fs used in determining the divisor in computing the facility's per diem rate.

3. Schedule B, Revenue and Costs: This schedule reports the revenues and costs incurred by the provider. The schedule begins with the facility's trial balance, and identifies revenue offsets, adjustments, and/or allocations necessary to arrive at the Medicaid reimbursable costs.

Part 1 identifies all revenues from patient services and any necessary offsets to Costs from these revenues. Part 2 Identifies other revenues realized by the facility and any necessary offsets to costs from these revenues. Part 3 identifies the facility's costs, summarizes the revenue offsets, summarizes the cost adjustments, and reports any necessary allocation of relmbursable costs. Part 4 summarizes the revenue and costs reported in parts 1, 2, and 3, and reports net income and identifies provision for income tax.

TN# NE 11-2 INANE 24 oroved _ APRAS 20 recive _1UL ~ 12041

TN# 10-19

OS Notification State/Title/Plan Number: NE 11-024 Type of Action: SPA Approval Required Date for State Notification: 05/24/2012

Fiscal Impact: FY 2011 ($1,247,016) FY 2012 ($4,988,062)

Number of Services Provided by Enhanced Coverage, Benefits or Retained Enrollment: 0

Number of Potential Newly Eligible People: 0

Eligibility Simplification: No

‘Provider Payment Increase: No

Delivery System Innovation: No Number of People Losing Medicaid Eligibility: 0 Reduces Benefits: No

Detail:

Effective July 1, 2011, this SPA proposes a 2.5% reduction in NF payment rates and proposes that ICF/MR payment rates do not receive an inflation adjustment for SFY 2012. The SPA also removes obsolete language and adds clarifying language enabling the State plan to flow from year-to-year eliminating the need for certain annual updates.

Although this SPA proposes a rate cut for NF services, the rate cut will not go into effect. The State also submitted SPA 11-029 which proposed a rate increase of 3.03% for NFs effective July 1, 2011 upon CMS approval of a new NF provider tax. On April 3, 2012, CMS approved the State’s request for a waiver of uniformity requirements and the new provider tax is effective July 1, 2011. The NIRT is processing SPA 11-029 for approval and when approved it will immediately supersede SPA 11-024. Therefore, the NF rate cut will never go into effect and the actual budget impact of SPA 11-024 is zero.

Since this SPA initially proposed a rate reduction, as part of our review we requested that the State provide information that supported their assertion that access to services would not be affected by the reduced rates. The State engaged providers, provider organizations and client representatives in 2011, and had several meetings with the Medical Assistance Advisory Committee, to communicate the Department’s fiscal limitations and legislative mandate to reduce expenditures. Providers expressed their disappointment about reductions, but understood the

current state budgetary circumstances and remained committed to serving the Medicaid population. The providers were also supportive of the new proposed provider tax which if approved would lead to rate increases.

In recent years, the State has been able to increase nursing facility and ICF/MR provider rates on an annual basis. From State Fiscal Year 2006 to 2011 provider rates were increased by an average of 2.92% per year. The NF rate reduction would have brought rates to levels that have, in the recent past, been adequate in maintaining provider enrollment and client access. For the period of January 1 through September 30, 2011, the overall average occupancy rate of Nebraska long term care facilities was 79%, with an excess of 3,500 beds available. The State has not seen a decrease in providers willing to care for Medicaid clients or an increase in client complaints about access to care. The State will ensure continued access to care through an active monitoring plan utilizing several measures such as provider participation, Medicaid enrollment and Inquiry lines calls, and service utilization for the fee-for-service population.

Other Considerations: Prior to submitting this SPA, the Nebraska Division of Medicaid Long-Term Care sought consultation from federally recognized Native American Tribes with the State to discuss the impact that the proposed SPA might have, if any, on the Tribes. No comments were received.

We do not recommend the Secretary contact the governor.

CMS Contact: Tim Weidler, NIRT 816-426-6429

ella aalamamnemmamasiaaaaiebemiaiabiniehiaiaeiniiia nee anne DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION OMB NO. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF 1. TRANSMITTAL NUMBER: 2. STATE STATE PLAN MATERIAL NE 11-24 ; Nebraska FOR: HEALTH CARE FINANCING ADMINISTRATION 3, PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) TO: REGIONAL ADMINISTRATOR 4. PROPOSED EFFECTIVE DATE HEALTH CARE FINANCING ADMINISTRATION July 1, 2011

DEPARTMENT OF HEALTH AND HUMAN SERVICES

5. TYPE OF PLAN MATERIAL (Check One): () NEW STATE PLAN

(] AMENDMENT TO BE CONSIDERED AS NEW PLAN

AMENDMENT

COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment) _

6. FEDERAL STATUTE/REGULATION CITATION:

7. FEDERAL BUDGET IMPACT: a.FFY 2011 $(1,247,016) b.FFY 2012 $(4,988,062)

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: Attachment 4.19-D, pp 1,2,10,13,15,16,16a,16b,17,18,25,27,28,31,32,

45,53,61,62,67,69,76

9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (if Applicable):

Attachment 4.19-D, pp 1,2,10,13,15,16,17,18,188,25,27,28,31, 32,45,53,61,62,67,69,76

10. SUBJECT OF AMENDMENT: Rate reduction for nursing facilities and ICF-MR

11. GOVERNOR’S REVIEW (Check One): (] GOVERNOR'S OFFICE REPORTED NO COMMENT

OTHER, AS SPECIFIED:

({] COMMENTS OF GOVERNOR’S OFFICE ENCLOSED Governor has waived review (] NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12. SIGNA’ F STATE AGENCY Lis E 16. RETURN TO: devi Patricia (Pat) Taft 13. veo we Ch t Division o' of Medicaid & 1.ong-Term Care in = aumony rent of Health & Human Services

Director, Division of Medicaid and Long-Term ox

15. DATE SUBMITTED:

___ September 12, 2011 FOR TESTONAT: OFFICE USE ONLY. : 18. DATE APPROVED: 17. DATE RECEIVED: APR 13 2012 PLAN APPROVED — ONE COPY ATTACHED ; ROVED MATERIAL: 20. SIG OF REGIONAL OFFICIAL: 19. EFFECTIVE DATE OF APP RAY not f

21. TYPED NAME: Penmeof hom (PSe AL

*6 Pe bay “Dwector, Cmes

23, REMARKS:

FORM HCFA-179 (07-92)

DEPARTMENT OF HEALTH &< HUMAN SERVICES Cenrer5 for Medicare & Mediceid Services CAIS 601 Eastl2-- Street. Suite 355 Kansas City. M.i$$Ouri 64106 Division of Medicaid and Oilldren's Health Operations March 7, 2012 Vivianne Chaumont, Director Department of Health & Human Services Division of Medicaid and Long Term Care 301 Centennial Mall S., 5th Floor PO Box 95026 Lincoln, Nebraska 68509 Dear Ms. Chaumont: On August 10, 2011, the Centers for Medicare & Medicaid Services (CMS) received Nebraska's State Plan Amendment (SPA) transmittal #11-025, ....niGh proposes to reduce the fee schedule rates for clirOcal laboratory servioes by 2.5% with a proposed effective date of July I, 2011. This SPA 11-025 was approved on March 6, 2012 with an effective date of July I, 2011 as requested by the state. Enclosed is a copy of the CMS-179 form, as well as, the approved pages for incorporation into the Nebraska State plan. If you have any questions regarding this amendment, please contact Narinder Singh at (816) 426-5925 or Narinder.Singh@cms.hhs.gov. '-"""'sociate Regional Adminis1rator for Medicaid and Children'S Health Operations Enclosure cc: Pat Taft

ATTACHMENT 4.19-8 Item 3, Page 2 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State Nebraska METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES Clinical Diagnostic Laboratory SeIVices Payment for clinical diagnostic laboratory services, including collection of laboratory specimens by venipuncture or catheterization, is paid at 97 .5% of the fee schedule determined by Medicare. X-Ray Services For dates of service on or after August 1, 1989, NMAP pays a claim for both the teChnical and profeSSional components of x-ray services at the lower of: 1. The provider's submitted charge; or 2. The allowable amount for thaI procedure code in the Nebraska Medicaid Practitioner Fee Schedule In effect for that date of service. The allowable amount is indicated in the fee schedule as ­ a. The unit value multiplied by the conversion factor; . b. The invoice cost (indicated as "Ie" in the fee schedule); c. The maximum allowable dOllar amount; or d. Ihe reasonable charge for the procedure as determined by the Medicaid Division (Indicated as "BR" - by report or "RNE~ • rate not established - in the fee schedule). The Nebraska Medicaid Practitioner Fee Schedule is effective July 1 through June 30 of each year. ReYisions of the Fee SChedule: The Department reserves the right to adjust the fee schedule to: 1. Comply with changes in stale or federal requirements; 2. Comply with changes in nationally-recognized coding systems,as HCPCS and CPT; 3. Establish an initial allowable amount for a nevi procedure based on information that was not available when the fee schedule was established for the current year; and 4. Adjust the alk>wable amount when the Medicaid Division determines thai the current aUowable amount is: a. Not appropriate for the service provided; or b. Based on errors in data or calculation. TN #. NE 11-25 Supersedes Approval Date MAR aii 2012 Ef!edive Dale JUL 0 1 2D:l TN #. MS-OO-06

ATTACHMENT 4.19·8 Item 4b, Page 1 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State Nebraska METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT) SERVICES For EPSDT services provided on or after April 1, 1990, the following applies. For services reimbursed under the Nebraska Medicaid Practitioner Fee Schedule, NMAP pays for EPSDT services (except for clinical diagnostic laboratory services) at the lower of: 1. The providers submitted charge; or 2. The allowable amount for that procedure code in the Nebraska Medicaid Practitioner Fee SChedule for that date of service. The allowable amount is indicated in the fee schedule as ~ a. The unit value multiplied by the conversion factor; b. The Invoice cost (indie&ted as "Ie" in the fee schedule); C. The maximum allowable dollar amount or d. The reasonable charge for the procedure as determined by the Medicaid Division (indicated as "SR- - by report or "RNE~ • rate not established in the fee schedule). The Department pays (or Clinical Laboratory services ·at 97.5% of the fee schedule determined by MedIcare. NMAP pays for injections at the wholesale cost of the drug plus an administration fee determined by the Department. Only the administration fee Is paid when a physician uses vaccine obtained at no cost from the Nebraska Oepanmenl of Health and Human Services. The Nebraska Medicaid Practitioner Fee Schedule is effective July 1 through June 30 of each year. TN#. NE 11-25 JUL 0 I 2011 Supersedes ApprovalDa",MAR 0 ~ 2012 Effective Da(e _____ TN #. MS-OO-06

ATIACHMENT 4.19-B Item 6a, Page 1 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State Nebraska METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES PODIATRISTS' SERVICES NMAP pays for covered podiatry services at the lower of: 1. The provider's submitted charge; or 2. The allowable amount for that procedure code in the Nebraska Medicaid Prac1itioner Fee Schedule in effect for that date of service. The allowable amount is Indicated in the fee schedule as: B. The unit value multiplied by tile conversion factor; b. The invoice cost (indicated as "Ie" in the fee schedule); c. The maximum allowable dollar amount; d. For clinical laboratory services, including collection of laboratory specimens by venipuncture Of catheterization, payment is r.1ade at 97.5% of the fee schedule determined by Medicare. e. The reasonab~ charge for the procedure as determined by the Medicaid DIvision (indicale<J as "SR" - by repon or "RNE" - rale n<>t eslablished - in the fee schedu",) . Revisions of the Fee Schedule: The Department may adjust the fee schedule to: 1. Comply with changes in state or federal requirements; 2. Comply with changes in nationaUy·recognized coding systems, such as HCPCS and CPT; 3. Establish an initial allowable amount for a new procedure or 8 procedure that was previously K1entifieci as "RNE" or "BRit based on Inrormation that was not available when the fee schedule was established for the current year; and 4. Adjust the allowable amount when the Medicaid Division determines that the current allowable amount Is: a. Not appropriate for the service provided ; or b. Based on errors in data or calculation . TN#. NE 11-25 Super.edes Approval Date MAR 0 e 2012 Effective Dale JUL 0 1 2011 TN #. MS-OQ.Q6

ATIACHMENT 4.19-B Item 6b. Page 1 STATE PLAN UNDER TiTlE XIX OF THE SOCIAL SECURITY ACT Slate Nebraska METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES OPTOMETRISTS' SERVICES NMAP pays tOf covered optometrists' services at the lower of: 1. The provider's submitted charge; or 2. The allowable amount for that procedure code in the Nebraska Medicaid Practitioner Fee Schedule in effect for that date of service . Ttle allowable amount is indicated in the fee schedule as ' a, The unit value multiplied by the conversion (actor; b. The invoice cost (indicated as "Ie" in the fae schedule) - the provider's actual cost (including discounts) fram the providers supplier. The maximum invoice cost payable is limited to reasonable avajla~e cost; c. The maximum allowable dollar amount; or d. For clinical laboratory services, including collection of laboratory specimens by venipuncture or catheterization, payment is 97.5% of the fee schedule determined by Medicare. e. The reasonable charge for the procedure as determined by the Medicaid Division (indicated as "BR" • by report or "RNE" - rate not established - in the fee schedule). Revisions of the Fee ScheduJe: The Oepanment may adjust the fee schedule to: 1. Comply with changes in state or federal requirements: 2. Comply with changes in nationally-recognized coding systems, such as HCPCS and CPT: 3 Establish an initial allowable amount for a new procedure or a procedure that was previously identified as ''RNEw or "BR" based on information thai was not available when the fee schedule was established for the current year; and 4. Adjust the allowable amount when the Medicaid Division determines that the current allowable amount is: 3. Not appropriate for the service provided; or b. Based on errors in data or calculation. Providers w~1 be notified of changes and their effective dates NMAP pays for injections at the wholesale cost of the drug plus an administration fee determined by the Depanment. TN~. NE 11-25 JUL 0 1 2011 Sl4>ersedes App.'l)val Date MAR 0 6 2012 Effec1ive Date _____ IN #. Ms-oo-06

ATTACHMENT 4.19-9 lIem 12d STATE PlAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State Nebraska METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES EYEGLASSES NMAP pays for covered eyeglasses at the lower of: 1. The provider's submitted charge; or 2. The allowable amount for thai procedure code in the Nebraska Medicaid Practrtioner Fee Schedule in effect for that date of service. The allowable amount is indicated in the tee schedule as: a. The unit value multiplied by the conversion factor; b. The invoice coal (indicated as "Ie" in the fee schedule) - the provider's actual cost (including discounts) from the provider's supplier. The maximum invoice cost payable Is limited to reasonable available cost; c. The maximum allowable dollar amount; or d, For clinical laboratory services, including collection of laboratory specimens by venipuncture or catheterization, payment is made at 97.5% of the fee schedule determined by Medicare. e. The reasonable charge for the procedure ss determined by the Medicaid Division (indicated as "BR" by report or "RNEM rate nol established in the fee schedule). Revisions of the Fee Schedule: The Oepar1ment may adjust the fee schedule to: 1. Compty with changes in state or federal requirements: 2. Compfy with changes in nationally-recognized coding systems, such as HCPCS and CPT; 3. Establish an initial allowable amount for a new procedure or a procedure that was previously identified as ~RNE" or "BR" based on information that was not available when the fee schedule was established for the current year: and 4. Adjust the allowable amount when the Medicaid Division determines that the current allowable amount is: a. Not appropriate for the service provided; or b Based on errors in data or calculation. Providers will be notified of changes and their effective dates. TN#. NE "-25 Approval Date _Id_IA_R_O_o_2012 Suptnedes Effective Date JUL °1 2011 TN #. MS-OO-06

- - - -- - ------ - UlirARTMl-:NT 01' III:ALTlI ,\.),,'0 1IlJM"'"" SERVICES FORM AI'PRl)VI,f) IIE,I,Lnl (;111(1, FINANCING AI)MINrSTRATION OM13 NO. 09JS-o r9.l TRANSMITTAL AND NOTICE OF APPtWVAL-OF·--- · I. TRA~SMIl1 'AL NUMBER:- 12. STATE STATt PLAN MATERIAL I J-25 Ncbrnska fOR, HI:Al.TIl CARE FINANCING ADMINISTRATION 3. PROGRAM IDENTIFICATlcJN:-TITLE XIXOFlll E ---­ SOCIAL SECURITY ACT (MEDICAIl)} TO: RF.(iIONAL AIJMINI STRKrO~-· '- ----·--- ---­ ·4.viWPOsED HrOCTIVF: n ATE HEALTH CARE PINANCING ADMINISTRATION I July J. 2011 DEPARTMENT Of ill:" LTH AND IIUMAN ~ER y"[ _ __ _ ____......._.w _ _ __•. __ <': l~S_ ----L. _ _ _______ 5, TYPE OF PLAN MATER.IAL (Check Olle): o NEW STATE PLAN 0 AMENDMENT TO BE CONSIOERED AS NEW f"LAN t8I AMENDM e NT COMPLETE 8LOCKS 6 THRU 10 IF ·n11S IS AN AMENDMl--:NT Se urUle TrQlUmjlltJf or e.uc/IIIMcndmem) 6"7EDER~\1. STATU;j-EfREGULATJON CITATION: ­ 8. PAGE NUMBER 6~-niEjij"~ANsECTioN ORATTACHMENT: AltllChment 4.19-U, Itcm:3, ptlf:!;l! 2 Allachmcnt 4.19· 13, hel1l4b, page I Anac:hm.::nt 4.19-B, He-Ill 6~, pa:;c I AUach'llcn! 4.19-U, llem 6b, page I /Illachml'!lt 4. 19-0, Ilem 12d ~==~=;;=-.---­ 10. SUOJ[CTOF AMENDME:.'NT: Laboratory fee :>c hcnulr; reduction. II . GOVERNOR'S REVIEW (Check One): o GOVERNOR'S OFFICE REPORTEil NO COMMENT o COMMENTS OF <1QVERNOR'S OFf·ICE ENCLOSED 0 1\'0 REPLY RECEIVED WIT!nN 45 DA VS OF SUHMITIAL ~1dU~~Z,~&~~~t.. _;'.;;'!~~.M.Q~".~"L___.______._____ .. 7. r EDERAL BlJlXiET IMPACT: -- ­ a. rry 2011 $(19.471) b. Fry 20 12 £(77,8R2) _ 9. F'AGE NUMREU OF THE SUPERSEDED Pl.AN SEC.TlON OR A1-rACUMBNT (IfA,1plicl.lble) : Attlchmcnt4 .19-B, Item J, page 2 AnachmenI4.J9·B, lto.!n14b. pllge I AllachlTlenl4.19· B, Ilcm 6a, page I Altachmenl d.19·R, Item 6b, pilge I ~.\~c h men! 4, 19·8, l1em 12U fSI OTHER, AS SPEC/PlEO: Governor ha\ waive.d review ._ _ .. __-I Patricia Wall Taf'! _________....j I1jvisinn of Medicaid &. Long.Tctm Care Nebraska: Department of Hcah.h & Human Services -i1~!¥it~If.f,~t~fk~1£~~"!'.'!J..-<'~:I!'!~.9rr_---'- -1 ) 01 Ceotconi.1 Mall SOUlh 1 ' Linculn, NE 68509 15. 1 '1 F()KM HCFA- 179 (07·92)

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services

601 East 12" Street, Suite 355

Kansas City, Missouri 64106

Division of Medicaid and Children’s Health Operations

CMTS

CENTERS for MEDICARE & MEDICAID SERVICES

March 7, 2012

Vivianne Chaumont, Director Department of Health & Human Services Division of Medicaid and Long Term Care 301 Centennial Mall S., 5th Floor

PO Box 95026

Lincoin, Nebraska 68509

Dear Ms. Chaumont:

On August 23, 2011, the Centers for Medicare & Medicaid Services (CMS) received Nebraska’s State Plan Amendment (SPA) transmittal #11-028, which proposes to reduce the fee schedule rates by 2.5% with a proposed effective date of July 1, 2011.

This SPA 11-028 was approved on March 6, 2012 with an effective date of July 1, 2011 as requested by the State. Enclosed is a copy of the CMS-179 form, as well as, the

approved page for incorporation into the Nebraska State plan.

If you have any questions regarding this amendment, please contact Narinder Singh at

(816) 426-5925 or Narinder.Singh@cms.hhs.gov.

ic OF ae

es OK Scott

sociate Regional Administrator in Medicaid and Children’s Health Operations

Enclosure

cc: Pat Taft

ATTACHMENT 4.19-B Item 1

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State Nebraska

Except as otherwise noted in the plan, state developed fee schedule rates are the same for both government and private providers and the fee schedule and any annual/periodic adjustments to the fee schedule are published at htto:/Avww.dhhs.ne.gov/med/provhome.htm (Division of Mecicaid and Long-Term Care website). The above mentioned fee schedule is applicable to all services reimbursed via a fee schedule. The agency's rates were set as of July 1, 2011 and are effective for services on or after that date.

TN No, NE 11-28 MAR 0 ' Supersedes Approval Date 6 aut Effective Date JUL 0 1 201

TN No., NE. 10-20

DEPARTMEN'T OF HEALTH AND HUMAN SERVICES HEALTH CARE FINANCING ADMINISTRATION

FORM APPROVIED OMB NO, 9938-0193

TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL

FOR: HEALTH CARE FINANCING ADMINISTRATION

‘3, PROGRAM IDENTIFICATION; TIT!

1. TRANSMITTAL NUMBER: NE 11-28

2, STATE Nebraska

SAID)

SOCIAL §

SCURITY ACT (MED.

TO: REGIONAL ADMINISTRATOR HFALTH CARE FINANCING ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES

4, PROPOSED EFFECTIVE DATE July 1, 2011

5. TYPE OF PLAN MATERIAL (Check One:

(1 NEW STATE PLAN

1] AMENDMENT TO BE CONSIDERED AS NEW PLAN

&] AMENDMENT

COMPLET

SLOCKS 6 THRU OTE THIS TS AN AMENDMENT (Separate Transnultal for each ainendment)

SDERAL BUDGET IMPACT: a FFY 2011 $1,209,366) b. FFY 2012 $(4,117,464)

fe

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

Attachment 4.19-B, Item t

9, PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (/f Appticabley:

Attachment 4.19-B, Item 1

10. SUBJECT OF AMENDMENT: Fee Schedule Rates 11, GOVERNOR’S REVIEW (Check One): (] GOVERNOR’S OFFICE REPORTED NO COMMENT (I OTHER, AS SPECIFIED: '] COMMENTS OF GOVERNOR’S OFFICE ENCLOSED Governor has waived review (C1 NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12, SIGNATUBE OF STATE AGENCY OFFICIAL 16. RETURN TO: aaeyoreny < ————~---=-ni_ Datrigia (Pat) Taft 13. atin vianmont Division of Medicaid & Long-Term Care ; id TLE: : Nebraska Department of Health & Human Services neuer . sat 1 - 301 Centennial Mall South Director, Division of Medicaid and Long-Term Care Lincoln, NE 68509 15. DATE SUBMITTED: oa August 23, 2011 FOR REGIONAL OFFICE USE ONLY 17, DATE RECEIVED: 18. DATE APPROVED: August...23-201 March 1.2018 PLAN APPROVED - ONE COPING TCHR __. 19, EFFECTIVE DATE ‘ ASRROVED MATERIAL: .§ 4 Llu, 22! “SL TVRED NAMES nal Adminishratar ‘G_Scol- coc fons

RKS:

FORM HCPA-179 (07-92)

DEPARTMENT OF HEALTH & HUMAN SERVICES CII. Ay Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12

ENTERS for MEDICARE & MEDICAID SERVICES Baltimore, Maryland 21244-1850 CENTERS for 4

Center for Medicaid and CHIP Services

apr 18 202

Vivianne M. Chaumont, Director

Division of Medicaid and Long-Term Care Nebraska Department of Health and Human Services 301 Centennial Mall South

Lincoln, Nebraska 68509

RE: Nebraska State Plan Amendment TN: 11-29

Dear Ms. Chaumont:

We have reviewed the proposed amendment to Attachment 4.19-D of your Medicaid State plan submitted under transmittal number (TN) 11-29. This amendment proposes a 3.03% rate increase for nursing facility payment services. The rate increase is to be funded by the new Nursing Facility Quality Assessment.

We conducted our review of your submittal according to the statutory requirements at sections 1902(a)(13), 1902(a)(30), and 1903(a) of the Social Security Act and the implementing Federal regulations at 42 CFR 447 Subpart C. This is to inform you that Medicaid State plan amendment 11-29 is approved effective July 1, 2011. We are enclosing the HCFA-179 and the amended plan pages.

If you have any questions, please call Tim Weidler at (816) 426-6429. Sincerely, 2 [wompo—

Cindy Mann Director, CMCS

Enclosures

ATTACHMENT 4.19-D Page 13

12-011.06P_ Other Limitations: Other limitations to specific cost components of the rate are included in the rate determination provision of this system.

12-011.06Q Nursing Facility Quality Assessment: The nursing facility quality assessment is an allowable cost addressed through the Nursing Facility Quality Assessment Component.

12-011.07 (Reserved)

12-011.08 Rate Determination: The Department determines rates for facilities under the following cost-based prospective methodology.

12-011.08A Rate Period: The Rate Period is defined as July 1 through June 30. Rates paid during the Rate Period are determined (see 471 NAC 12011.08D) from cost reporis submitted for the Report Period ending June 30 two years prior to the end of the Rate Period. For example, cost reports submitted for the Report Period ending June 30, 2009 determine rates for the Rate Period July 1, 2010 through June 30, 2011.

12-011.08B Report Period: Each facility must file a cost report each year for the reporting period of July 1 through June 30.

12-011.08C Care Classifications:. A portion of each individual facility's rate may be based on the urban or non-urban location of the facility.

12-011.08D_ Prospective Rates: Subject to the allowable, unallowable, and limitation provisions of 471 NAC 12-011.04, 12-011.05, and 12-011,06, the Department determines facility-specific prospective per diem rates (one rate corresponding to each level of care) based on the facility's allowable costs incurred and documented during the Report Period. The rates are based on financial, acuity, and statistical data submitted by facilities, and are subject to the Component maximums.

Component maximums are computed using audited data following the initial desk audits, and are not revised based on subsequent changes to the data. Only cost reports with a full year's data are used in the computation. Cost reports from providers entering or leaving Medicaid during the immediately preceding Report Period are not used in the

computation.

Each facility's prospective rates consist of four components:

1. The Direct Nursing Component adjusted by the inflation factor;

2. The Support Services Component adjusted by the inflation factor; 3. The Fixed Cost Component; and

4. The Nursing Facility Quality Assessment Component.

t The Direct Nursing Component and the Support Services Component are subject to maximum per diem payments based on Median/Maximum computations.

- 2 . es poroes APR ESTP og JUL = 220 TN# NE 11-24

ATTACHMENT 4.19-D Page 15

42-011,08D3 Fixed Cost Component: This component of the prospective rate is computed by dividing the facility's allowable interest, depreciation, amortization, long-term rent/lease payments, personal property tax, real estate tax, and other fixed costs by the facility's total inpatient days (see 471 NAC 12-011.06B). Rate determination for the Fixed Cost Component for an individual facility is computed using the lower of its own per diem as computed above, or a maximum per diem of $27.00 excluding personal property and real estate taxes.

12-011,08D4 Nursing Facility Quality Assessment Component: The Nursing Facility Quality Assessment component shall not be subject to any cost limitation or revenue offset.

The quality assessment component rate will be determined by calculating the ‘anticipated tax payments’ during the rate year and then dividing the total anticipated tax payments by ‘total anticipated nursing facility/skilled nursing facility patient days,’ including bed hold days and Medicare patient days.

For the rate year beginning July 1, 2011, the ‘anticipated tax payments’ will be determined by annualizing total facility patient days, including bed hold days, less Medicare days from the time period beginning January 1, 2011 and ending June 30, 2011. ‘Total anticipated nursing facility/skilled nursing facility patient days’ will be determined by annualizing total facility patient days, including bed hold days and Medicare days, from the time period beginning January 1, 2011 and ending June 30, 2011. Nursing Facilities will not be assessed a tax on any patient days prior to July 1, 2011.

For each subsequent rate year, total facility patient days, including bed hold days, less Medicare days, for the four most recent calendar quarters available at the time tates are determined will be used to calculate the ‘anticipated tax payments.’ Total facility patient days, including bed hold days and Medicare days, for the same four calendar quarters will be used to calculate the ‘anticipated nursing facility/skilled nursing facility patient days.’

12-011.08D5 Inflation Factor: For the Rate Period of July 1, 2011 through June 30, 2012, the inflation factor is positive 3.03%.

TN# NE 41-29

01 Supersedes Approved APR 18 2012 Effective JUL - i 2011

TN# NE 11-24

ATTACHMENT 4.19-D Page 15a

12-011,08E Exception Process: An individual facility may request, on an exception basis, the Director of the Division of Medicaid and Long-Term Care to consider specific facility circumstance(s), which warrant an exception to the facility's rate computed for its Fixed Cost Component. An exception may only be requested if the facility's total fixed costs {total costs, not per diem rate), as compared to the immediately prior report period, have increased by ten percent or more. In addition, the facility's request must include:

1. Specific identification: of the increased cost(s) that have caused the facility's total fixed costs to increase by 10 percent or more, with Justification for the reasonableness and necessity of the increase;

2. Whether the cost increase(s) are an ongoing or a one-time occurrence in the cost of operating the facility; and

3. If applicable, preventive management action that was implemented to control past and future cause(s) of identified cost increase(s).

12-011.08F Rate Payment for Levels of Care 101, 102, 103 and 104; Rates as determined for Levels of Care 101, 102, 103 and 104 under the cost-based prospective methodology of 471 NAC 12-011.08A through 12-011.08E may be adjusted for actual payment. The payment rate for Levels of Care 101, 102, 103 and 104 is the applicable rate in effect for assisted living services under the Home and Community-Based Waiver Services for Aged Persons or Adults or Children with Disabilities (see 480 NAC 5),

12-01 -of- ilities: The Department pays out-of-state facilities participating In Medicaid at a rate established by that state's Medicaid program at the time of the issuance or reissuance of the provider agreements. The payment is not subject to any type of adjustment.

TN# NE. 11-29 APR 13 2012 JUL 2.2011 Supersedes Approved ‘ Effective

TN# New page

OS Notification State/Title/Plan Number: NE 11-029 Type of Action: SPA Approval Required Date for State Notification: 04/30/2012

Fiscal Impact: FY 2011 $ 4,810,480 FY 2012 $19,241,917

Number of Services Provided by Enhanced Coverage, Benefits or Retained Enrollment: 0

Number of Potential Newly Eligible People: 0 Eligibility Simplification: No

Provider Payment Increase: Yes

Delivery System Innovation: No Number of People Losing Medicaid Eligibility: 0 Reduces Benefits: No

Detail:

Effective July 1, 2011, this SPA proposes a 3.03% across the board increase in NF payment rates. The increase will be funded by the new Nursing Facility Quality Assessment, the State’s new NF provider tax. On April 3, 2012, CMS approved the State’s request for a waiver of uniformity requirements and the new provider tax is effective July 1, 2011. Approval of SPA 11-029 negates the effects of a 2.5% reduction in NF rates proposed under SPA 11-024 which would have gone into effect on July 1, 2011 had SPA 11-029 and the new provider tax not been approved.

Other Considerations: Prior to submitting this SPA, the Nebraska Division of Medicaid Long-Term Care sought consultation from federally recognized Native American Tribes with the State to discuss the impact that the proposed SPA might have, if any, on the Tribes. No comments were received.

We do not recommend the Secretary contact the governor.

CMS Contact: Tim Weidler, NIRT 816-426-6429

DEPARTMENT OF HEALTH AND HUMAN SERVICES

FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION OMB NO. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF 1. TRANSMITTAL NUMBER: 2. STATE STATE PLAN MATERIAL 11-29 Nebraska

FOR: HEALTH CARE FINANCING ADMINISTRATION

3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID)

TO: REGIONAL ADMINISTRATOR HEALTH CARE FINANCING ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES

4. PROPOSED EFFECTIVE DATE July 1, 2011

5. TYPE OF PLAN MATERIAL (Check One): (NEW STATE PLAN

(J) AMENDMENT TO BE CONSIDERED AS NEW PLAN

({<] AMENDMENT

COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment)

6. FEDERAL STATUTE/REGULATION CITATION:

7. FEDERAL BUDGET IMPACT:

a FFY 2011 $ 4,810,480 b, FFY 2012 $19,241,917 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: | 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION . OR ATTACHMENT (ff Applicable): Attachment 4.19-D, pages 13, 15,15a Attachment 4.19-D, pages 13, 15 10. SUBJECT OF AMENDMENT: Implement nursing facility provider tax. 11. GOVERNOR’S REVIEW (Check One): [([] GOVERNOR’S OFFICE REPORTED NO COMMENT OTHER, AS SPECIFIED: [_] COMMENTS OF GOVERNOR’S OFFICE ENCLOSED Governor has waived review

CJ NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

12, SIGHATURE OF STATE AGENCY OFFICIAL: 16. RETURN TO: ALi VA 13. TYPED NAME: Nancy Keller

Division of Medicaid & Long-Term Care

Vivianne M. Chaumont

14, TITLE: Director, Division of Medicaid and Long-Term Cate

15. DATE SUBMITTED:

September 26, 2011

FOR REGIONAL OFFICE USE ONLY

17. DATE RECEIVED:

18. DATE APPROVED:

APR 18 2012

PLAN APPROVED — ONE

COPY ATTACHED

| 19. EFFECTIVE DATE OF APPROVED “aL 4 - 100i

20. SIGNATURE OF REGIONAL OFFICIAL:

21, TYPED NAME: ve AWS Them pSou

23. REMARKS:

22 { Pay Directo, cCmes

FORM HCFA-179 (07-92)

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Cf. AY 601 East 12" Street, Suite 355 Kansas City, Missouri 64106 CENTERS for MEDICARE & MEDICAID SERVICES Division of Medicaid and Children’s Health Operations

March 19, 2012

Vivianne M. Chaumont, Director Department of Health and Human Services Division of Medicaid and Long-Term Care 301 Centennial Mall S., 5" Floor

P.O. Box 95026

Lincoin, Nebraska 68509-5026

Dear Ms, Chaumont:

On December 30, 2011, the Centers for Medicare & Medicaid Services (CMS) received Nebraska’s State Plan Amendment (SPA), transmittal #1 1-32 through which the State is attesting compliance with Section 4107 of the Patient Protection and Affordable Care Act (Affordable Care Act), P.L. 111-148. This amendment provides for Medicaid coverage of comprehensive tobacco cessation services for pregnant women, including both counseling and pharmacotherapy, without cost sharing. This provision was effective July 1, 2011.

Based upon the information received, CMS approved SPA #11-32 on March 19, 2012, with an effective date of October 1, 2011. Enclosed is a copy of the CMS 179 form, as well as, the approved pages for incorporation into the Nebraska Medicaid State plan. If you have any questions regarding this amendment, please contact Sandra Levels at Sandra.Levels@cms.hhs.qgov or (816) 426-5925.

Sine

ly

/f

Associate Regional Administrator for Medicaid and Children’s Health Operations

Enclosure

ce: Margaret Brockman

Revision: HCFA-PM-93-5 (MB) Attachment 3.1-A May 1993 Page 2 OMB Nao.:

State: Nebraska

AMOUNT, DURATION AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY

4.a. Nursing facility services (other than services in an institution for mental diseases) for individuals 21 years of age or older.

Provided: (1 No fimitations With limitations*

b. Early and periodic screening, diagnostic and treatment services for individuals under 21 years of age, and treatment of conditions found.*

Provided: C) No limitations With limitations* c. Family planning services and supplies for individuals of child-bearing age.

Provided: CD Na limitations XX] With limitations* d. 1) Face-to-Face Tobacco Cessation Counseling Services provided (by):

Gi) By or under supervision of a physician;

&) (ii) By any other health care professional who is legally authorized to furnish such services under State law and who is authorized to provide Medicaid coverable services other than tobacco cessation services; or

C1 (ili) Any other health care professional lagaily authorized to provide tobacco cessation services under State law and who Is specifically designated by the Secretary in regulations. (None are designated at this time; this item is reserved for future use.) *describe if there are any limite on who can provide these counseling services.

2) Face-to-Face Tobacco Cessation counseling Services Benefit Package for Pregnant Women .

Provided: & No limitations CJ With timitations*

*Any benefit package that consists of fess than four (4) counseling sessions per quit attempt, with a minimum of two (2) quit attempts per 12 month period (eight (8) per year) should be explained below,

Please describe any limitations:

TN No. NE=11-32 Supersedes Approval Date MAR? 9 2012 — Effective Date: OLT . Q 1 201 TN No. MS-00-06 HCFA ID: 7986E

Revision: HCFA-PM-93-5 (MB) Altachment 3.1-A May 1993 Page 2a OMB No.:

_ State: Nebraska

AMOUNT, DURATION AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY

5.a. Physicians' services whether fumished in the office, the patient's home, a hospital, a nursing

facility or elsewhere, Provided: [No limitations EX With limitations" b. Medical and surgical services furnished by a dentist (in accordance with section 1905(a)(5)(B) of the act). Provided: (1 Neo limitations EJ With fimitations*

6. Medical care and any other type of remedial care recognized under State law, furnished by licensed practitioners within the scope of their practice as defined by state law.

a. Podiatrists’ services.

Provided: () No limitations & With limitations*

* Description provided on attachment

TN No. NE-11-32 Supersedes Approval Date MARL 2202 Effective Dat. OCT 0 1 2011

TN No. New Page HCFA ID: 7986E

Revision: HCFA-PM-91- (BPD) : ATTACHMENT 3.1-B 1991 Page 2 OMB No.: 0938

State/Territory: Nebraska

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED MECICALLY NEEDY GROUP(S): ___All Groups

1. Inpatient hospital services other than those provided in an institution for mental diseases, Provided C1 _ No limitations EI With Limitations‘ 2. a. Outpatient hospital services. (J Provided 0 Ne limitations J With Limitations*

b. Rural health clinic services and other ambulatory services furnished by a rural health clinic (which are otherwise included in the State Plan)

Provided C1 _ No limitations —] With Limitations*

c. Federally qualified health center (FQHC) services and other ambulatory services that are covered under the plan and furnished by an FOHC in accordance with sec. 4231 of the State Medicaid Manual (HCFA-Pub. 45-4).

—] Provided O1 Ne limitations {] With Limitations* 3. Other laboratory and x-ray services. Provided [J No limitations [) With Limitations”

4. a. Nursing facility services (other than services in an institution for mental diseases) for individuals 21 years of age or older.

BJ = Provided (1 _ No imitations ] With Limitations*

b. Early and periodic screening, diagnostic and treatment services for individuals under 21 years of age, and treatment of conditions found.

BI) Provided 0 No limitations & With Limitatione* c. Family planning services and supplies for individuals of child-bearing age. {) Provided LC] No limitations J With Limitations* “Description provided on attachment

TN No. NE-11-32 Supersedes Approval Date MAR 7 9 2012 effective Dath OCT Q-1.2011

TN No. MS-00-06 HCFA ID: 7988E

Revision. HCFA-PM-93-5 (MB) ATTACHMENT 3.1-B MAY 1993 Page 2a OMB No.:

.. State/Territory: Nebraska

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED MEDICALLY NEEDY GROUP(S): ___All Groups

d, 1) Face-to-Face Tobacco Cessation Counseling Services provided (by):

(i) By or under supervision of a physician;

&I (i) By any other health care professional who is legafly authorized to furnish such services under State law and who is authorized to provide Medicaid coverable services other than tobacco cessation services; or

CO (ii) Any other health care professional legally authorized to provide tobacco cessation services under State law and who is specifically designated by the Secretary in regulations. (None are designated at this time; this itam is reserved for future use.) “describe if there are any timits on who can provide these counseling services.

2) Face-to-Face Tobacco Cessation counseling Services Benefit Package for Pregnant Women .

Provided: No limitations (J With limitations*

*Any benefit package that consists of Jess than four (4) counseling sessions per quit attempt, with a minimum of two (2) quit attempts per 12 month period (eight (8) per year) should be explained below.

Please describe any limitations: \

5, a. Physicians’ services whether fumished in the office, the patient's home, a hospital, a nursing facility or elsewhere,

& Provided No limitations With Limitations*

b. Medical and surgical services fumished by a dentist (In accordance with section 1905(a)(5){B) of the act).

Provided Cl Nolimitations El = With Limitations*

“ Deacription provided on attachment.

TN No. NE-11-32 Supersedes Approval Date MAR 19 2012 Effective DateQCT 9.1 2011

TN No. MS-00-06

Reprised Stlorei Si an 3.13 QO?

ATTACHMENT 3.1-A

item 12a, Page 2 of 2 Applies to both Categorically and Medically Needy

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State Nebraska LIMITATIONS - PRESCRIBED DRUGS

6. Agents when used to promote smoking cessation. (Restricted to the prescription drugs, bupropion and varenicline, and over-the-counter nicotine patches and nicotine gum. Prescription drugs are covered for Medicaid recipients who are not full-benefit dual eligible individuals. Over-the counter drugs are covered for all populations. Coverage of all prescription and over- the-counter agents is available to only those Medicaid recipients that are enrolled with and actively participating in the Nebraska Tobacco-Free Quitline.)

) The Medicaid agency will provide coverage of prescription and over-the- counter (OTC) tebacco/smoking cessation covered outpatient drugs for pregnant women as recommended in “Treating Tobacco Use and Dependence: 2008 Update: Clinical Practice Guideline’ published by the Public Health Service in May 2008 or any subsequent modification of such guideline.

Ki 7. Preseription vitamins and mineral products, except prenatal vitamins and fluoride preparations.

BJ 8 Nonprescription drugs (All drugs in this category are potential benefits, subject to medical necessity). Covered over the counter (OTC) classes include analgesics, anesthetics, anti-infammatory products, anti-asthmatics, antihistamines, anti-infectives, cough and cold preparations, eye, ear and nose preparations, gastrointestinal products, hypoglycemic, smoking deterrents, and topicals.

Xi] 9. Covered outpatient drugs which the manufacturer seeks to require as a condition of sale that associated tests or monitoring services be purchased exclusively from the manufacturer or its designee.

EF 10. Drugs described in section 107(¢}(3) of the Drug Amendments of 1962 and identical, similar, or related drugs (within the Meaning of Section 310.6(b)(1) af title 21 of the Code of Federal Regulations (DESI drugs)

11. Barbiturates

12. Benzodiazepines (generic only)

Telehealth: Pharmacy services for prescribed drugs are not covered when provided via telehealth technologies.

Supersedes Approval Date MAR 1 9 2012 Effective Date Tt TN No. MS-08-15

DEPARTMENT OF HEALTH AND HUMAN SERVICES. FORM APPROVED

HEALTH CARE FINANCING ADMINISTRATION OMB NO. 9938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF 1. TRANSMITTAL NUMBER: 2. STATE STATE PLAN MATERIAL 11-32 Nebraska FOR: HEALTH CARE FINANCING ADMINISTRATION 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) TO: REGIONAL ADMINISTRATOR 4, PROPOSED EFFECTIVE DATE HEALTH CARE FINANCING ADMINISTRATION : October 1, 2011

DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One):

(J NEW STATE PLAN [] AMENDMENT TO BE CONSIDERED AS NEW PLAN AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment) 6, FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: i a. FFY 2012 $0 ' b. FFY 2013 $0

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: =| 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (if Applicable):

Attachment 3.1-A Page 2

Attachment 3.1-A Page 2a (new page) Attachment 3.1-A Page 2 Attachment 3.1-A Item 12a, Page 2 of 2 Attachment 3.1-A Item 12a, Page 2 of 2 Attachment 3.1-B Page 2a Attachment 3.1-B Page 2a

10. SUBJECT OF AMENDMENT: Tobacco Cessation-updating to reflect changes to comply with Affordable Care Act

11, GOVERNOR’S REVIEW (Check One): [] GOVERNOR’S OFFICE REPORTED NO COMMENT X] OTHER, AS SPECIFIED: (J) COMMENTS OF GOVERNOR'S OFFICE ENCLOSED Governor has waived review [2 NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

12, Pa OF STATE AGENCY OFFICIAL: 16. RETURN TO:

13. TYPED NAME: Nancy Keller

a Division of Medicaid & Long-Term Care 14 wane M. Chaumont Nebraska Department of Health & Human Services te ae +s 301 Centennial Mall South Director, Division of Medicaid and Long-Term Care Lincoln, NE 68509

15. DATE SUBMITTED: “December 30, 2011

FORM HCFA-179 (07-92)

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services 601 East 12th Street, Suite 355 Kansas City, Missouri 64106

Division of Medicaid and Children's Health Operations

October 25,, 2012

Vivianne Chaumont, Director Nebraska Department of Health & Human Services Division of Medicaid & Long Term Care 301 Centennial Mall S., 5th Floor PO Box 95026 Lincoln NE 68509

Dear Ms. Chaumont:

On April 11, 2012, the Centers for Medicare & Medicaid Services (CMS) received Nebraska’s State Plan Amendment (SPA) for PACE, transmittal # 12-04, which is a voluntary managed care program for persons age 55 and older. This PACE program will provide additional long-term care options for eligible individuals, age 55 and older, by offering a comprehensive array of Medicare & Medicaid institutional and community- based services for those who meet a nursing facility level of care and live in the designated service area of a PACE provider. These PACE services include: primary care, physician and nursing services, social services, social restorative therapies, physical and occupational therapy, personal care and supportive services, nutritional counseling, recreational therapy, and meals. PACE provider organizations assume financial risk for the full range of preventive, primary, acute, and long-term care services.

Based on the information provided, this SPA is approved as of October 24, 2012, with an effective date of February 1, 2013 as requested by the State. Enclosed is a copy of the CMS 179 form, as well as, the approved pages for incorporation into the Nebraska State Plan. If you have any questions regarding this amendment, please call Sandra Levels at (816) 426-5925.

Sincerely,

/s/

James G. Scott Associate Regional Administrator

for Medicaid and Children’s Health Operations

Enclosure

cc: Nancy Keller Julie Docter

19c State/Territory: Nebraska Citation 3.1 (a)(1) Amount, Duration, and Scope of Services: Categorically Needy (Continued} 1905(a)(26) and 1934 TN No. NE 12-04 Supersedes TN No. New page X Program of All-Inclusive Care for the Elderly (PACE) services, as described and limited in Supplement 4 to Attachment 3.1-A. ATTACHMENT 3.1-A identifies the medical and remedial services provided to the categorically needy. (Note: Other programs to be offered to Categorically Needy beneficiaries would specify all limitations on the amount, duration and scope of those services. As PACE provides services to the frail elderly population without such limitation, this is not applicable for this program. In addition, other programs to be offered to Categorically Needy beneficiaries would also list the additional coverage -that is in excess of established service limits- for pregnancy-related services for conditions that may complicate the pregnancy. As PACE is for the frail elderly population, this also is not applicable for this program.) Oi'T 2 ,~ 2012 . Approval Date _ j ____ _ Effective Date Feb 01 .;)DI3

20c StatefT erritory: Nebraska Citation 3.1 (a}(2} Amount. Duration, and Scope of Services: Medically Needy (Continued) 1905(a)(26} and 1934 __x_ Program of All-Inclusive Care for the Elderly (PACE) services, as described and limited in Supplement 4 to Attachment 3.1-A. ATTACHMENT 3.1-B identifies services provided to each covered group of the medically needy. (Note: Other programs to be offered to Medically Needy beneficiaries would specify all limitations on the amount, duration and scope of those services. As PACE provides services to the frail elderly population without such limitation, this is not applicable for this program. In addition, other programs to be offered to Medically Needy beneficiaries would also list the additional coverage -that is in excess of established service limits- for pregnancy-related services for conditions that may complicate the pregnancy. As PACE is for the frail elderly population, this also is not applicable for this program.) TN No. NE 12-04 Supersedes Approval Date . OCT 2 L1 2012 Effective Date feb ()) ;/P/3 TN No. New page

Revision: HCFA-PM-91-4 August 1991 (BERC) Attachment 2.2 -A Page 11 OMB NO.: 0938- Statefferritory: Nebraska Citation 42 CFR 435.914 1902(a)(34) of the Act 1902(e)(8) and 1905(a) of the Act 1902(a)(47) and 42 CFR 438.6 2.1 (b) (1) Except as provided in items 2.1 (b)(2) and (3) below, individuals are entitled to Medicaid services under the plan during the three months preceding the month of application, if they were, or on application would have been, eligible. The effective date of prospective and retroactive eligibility is specified in Attachment 2.6-A. (2) For individuals who are eligible for Medicare cost-sharing expenses as qualified Medicare beneficiaries under section 1902(a)(1 O)(E)(i)of the Act, coverage is available for services furnished after the end of the month which the individual is first determined to be a qualified Medicare beneficiary. Attachment 2.6-A specifies the requirements for determination of eligibility for this group. rgj (3) Pregnant women are entitled to ambulatory prenatal care under the plan during a presumptive eligibility period in accordance with section 1920 of the Act. Attachment 2.6-A specifies the requirements for determination of eligibility for this group. (c) The Medicaid agency elects to enter into a risk contract that complies with 42 CFR 438.6, and that is procured through an open, competitive procurement process that is consistent with 45 CFR Part 74. The risk contract is with (check all that apply): D Qualified under Title XIII 1310 of the Public Health Service Act. rgj A Managed Care Organization that meets the definition of 1903(m) of the Act and 42 CFR 438.2. D A Prepaid Inpatient Health Plan that meets the definition of 42 CFR 438.2. D A Prepaid Ambulatory Health Plan that meets the definition of 42 CFR 438.2. D Not applicable. 42 CFR 1:8:1 4. A group or groups of individuals who would be eligible for Medicaid 435.217 under the plan if they were in a NF or an ICF/MR, who but for the provision of home and community-based services under a waiver granted under 42 CFR Part 441, Subpart G would require institutionalization, and who will receive home and community- based services under the Waiver. The group or groups covered are listed in the waiver request. This option is effective on the effective date of the State's section 1915(c) waiver under which this group(s) is covered. In the event an existing 1915(c) waiver is amended to cover this group(s), this option is effective on the effective date of the amendment. ~ This includes PACE enrollees who reside in the community who are eligible using institutional rules. *Agency that determines eligibility for coverage. TN No. NE 12-04 Supersedes TN No. MS-03-12 Approval Date OCT 2 L1 2012 Effective Date F~ OJ ;J!)J3

Revision: HCFA-PM-94-9 December 1994 (MB) Attachment 3.1-A Page 10 . State/Territory: Nebraska AMOUNT, DURATION AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY 25. Home and Community Care for Functionally Disabled Elderly Individuals, as defined described and limited in Supplement 2 to Attachment 3.1-A, and Appendices A-G to Supplement 2 to Attachment 3.1-A [8l Provided: 0 Not provided 26. Personal assistance services are those services provided to a Medicaid client who is not an inpatient or resident of a hospital, nursing facility, intermediate care facility for the mentally retarded, institution for mental disease, or prison, which are authorized on a written service plan according to individual needs identified in a written assessment. Personal assistance services are A) authorized by a Social Services Worker or designee, B) provided by qualified providers who are not legally responsible relatives, and C) are furnished inside the home, and outside the home with limitations. [8] Provided: D Not Provided t8l State Approved (Not Physician) Service Plan Allowed [8l Services Outside the Home Also Allowed [8l Limitations Described on Attachment 27. Program of All-Inclusive Care for the Elderly (PACE) services, as described in Supplement 4 to Attachment 3.1-A _lL Election of PACE: By virtue of this submittal, the State elects PACE as an optional State Plan service. No election of PACE: By virtue of this submittal, the State elects to not add PACE as an optional State Plan service 28. (i) Licensed or Otherwise State-Approved Freestanding Birth Center Provided: D No limitations r8:l With limitations D None licensed or approved Please describe any limitations: Facilities must: (a) Be specifically approved by Department of Health and Human Services, Division of Public Health to provide birthing center Services. (b) Maintain standards of care required by Department of Health and Human Services, Division of Public Health for licensure. TN No. NE 12-04 Supersedes TN No. NE 11-21 Approval Date OCT 2 L1 2012 Effective Date Feb OJ ;}/)[3 I' I !

Revision: HCFA-PM-94-9 December 1994 (MB) Attachment 3.1-A Page 10a State/Territory: Nebraska AMOUNT, DURATION AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY 28. (ii) Licensed or Otherwise State-Recognized covered professionals providing services in the Freestanding Birth Center Provided: D No limitations r:8l With limitations (please describe below) D Not Applicable (there are no licensed or State approved Freestanding Birth Centers Please check all that apply: J:8J (a) Practitioners furnishing mandatory services described in another benefit category and otherwise covered under the State plan (i.e. physicians and certified nurse midwives). D (b) Other licensed practitioners furnishing prenatal, labor and delivery, or postpartum care in a freestanding birth center within the scope of practice under State law whose services are otherwise covered under 42 CFR 440.60 (e.g., lay midwives, certified professional midwives (CPMs), and any other type of licensed midwife).* D (c) Other health care professionals licensed or otherwise recognized by the State to provide these birth attendant services (e.g., doulas, lactation consultant, etc.}.* TN No. NE 12-04 Supersedes TN No. NE 11-21 Approval Date OCT 2 t1 2012 Effective Date feb ()J .21JJ3

SUPPLEMENT 4 TO ATTACHMENT 3.1-A Page 1 OMB No.: 0939-0193 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT Staterrerritory: Nebraska I. Eligibility The State determines eligibility for PACE enrollees under rules applying to community groups. A _x_ The State determines eligibility for PACE enrollees under rules applying to institutional groups as provided for in section 1902(a)(1 O)(A)(ii)(VI) of the Act (42 CFR 435.217 in regulations). The State has elected to cover under its State plan the eligibility groups specified under these provisions in the statute and regulations. The applicable groups are: B. 1902(a)(1 O)(A)(ii)(XI) of the Act 1902(a)(1 O)(A)(ii)(X) and 1902(m)(1) and (3) of the Act 42 CFR 435.310 42 CFR 435.320 42 CFR 435.322 42 CFR 435.324 The State will use the actual maximum monthly allowable Special Needs Nursing Facility rate to reduce an individual's income to an amount at or below the medically needy income limit (MNIL) for persons who are medically needy with a Share of Cost. The State determines eligibility for PACE enrollees under rules applying to institutional groups, but chooses not to apply post-eligibility treatment of income rules to those individuals. (If this option is selected, skip to II- Compliance and State Monitoring ofthe PACE Program. C. _x_ The State determines eligibility for PACE enrollees under rules applying to institutional groups, and applies post-eligibility treatment of income rules to those individuals as specified below. Note that the post-eligibility treatment of income rules specified below are the same as those that apply to the State's approved HCBS waiver(s). D. ~ Spousal impoverishment eligibility rules are being applied. Regular Post Eligibility 1. _x_ SSI State. The State is using the post-eligibility rules at 42 CFR 435.726. Payment for PACE services is reduced by the amount remaining after deducting the following amounts from the PACE enrollee's income. (a). Sec. 435.726-States which do not use more restrictive eligibility requirements than SSI. TN No. NE 12-04 Supersedes TN No. New page Approval Date , OCT 2 L1 2012 Effective Date E~b bl ..2/J).J

SUPPLEMENT 4 TO ATTACHMENT 3.1-A Page 2 OMB No.: 0939-0193 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State/Territory: Nebraska 1. Allowances for the needs of the: (A.) Individual (check one) 1. _ The following standard included under the State plan (check one): (a) __ SSI (b) __ Medically Needy (c) __ The special income level for the institutionalized (d) __ Percent of the Federal Poverty Level: __ (e) __ Other (specify): _________ _ 2. _ The following dollar amount: $ ___ _ Note: If this amount changes, this item will be revised. 3 . ..x_ The following formula is used to determine the needs allowance: (a) For waiver clients receiving Assisted Living Services: The State protects the SSI standard. (b) For clients receiving waiver services in other eligible living arrangements: The State protects the medically needy income standard. Note: If the amount protected for PACE enrollees in item 1 is equal to, or greater than the maximum amount of income a PACE enrollee may have and be eligible under PACE, enter N/A in items 2 and 3. (B.) Spouse only (check one): 1 ._ SSI Standard 2. _ Optional State Supplement Standard 3. _ Medically Needy Income Standard 4. _ The following dollar amount: $ ___ _ Note: If this amount changes, this item will be revised. 5. _ The following percentage of the following standard that is not greater than the standards above: __ % of standard. 6. _ The amount is determined using the following formula: 7 . ....x_ Not applicable (N/A) (C.) Family (check one): 1. AFDC need standard 2 . ....x_ Medically needy income standard The amount specified below cannot exceed the higher of the need standard for a family of the same size used to determine eligibility under the State's approved AFDC plan or the medically needy income standard established under 435.811 for a family of the same size. TN No. NE 12-04 Supersedes TN No. New page Approval Date . OCT 2 tl 2012 Effective Date Feb {)/ :Jf)jJ

SUPPLEMENT 4 TO ATIACHMENT 3.1-A Page3 OMB No.: 0939-0193 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State/Territory: Nebraska 3. _ The following dollar amount: $-:--:-~- Note: If this amount changes, this item will be revised. 4. _ · The following percentage of the following standard that is not greater than the standards above: %of standard. 5. _ The amount is determined using the following formula: 6. Other 7. _ Not applicable (N/A) (2). Medical and remedial care expenses in 42 CFR 435.726. Regular Post Eligibility 2. 209(b) State, a State that is using more restrictive eligibility requirements than SSI. The State is using the post-eligibility rules at 42 CFR 435.735. Payment for PACE services is reduced by the amount remaining after deducting the following amounts from the PACE enrollee's income. (a) 42 CFR 435. 735--States using more restrictive requirements than SSI. 1. Allowances for the needs of the: (A.) Individual (check one) 1. _ The following standard included under the State plan (check one): (a)_ SSI . (b) _ Medically Needy (c)_ The special income level for the institutionalized (d)_ Percent of the Federal Poverty Level: % (e)_ Other (specify):_---=-------- 2. The following dollar amount: $ __ _ Note: If this amount changes, this item will be revised. 3. The following formula is used to determine the needs allowance: Note: If the amount protected for PACE enrollees in item 1 is equal to, or greater than the maximum amount of income a PACE enrollee may have and be eligible under PACE, enter N/A in items 2 and 3. (8.) Spouse only (check one): TN No. NE 12-04 Supersedes TN No. New page 1. _ The following standard under 42 CFR 435.121 : 2. _ The Medically needy income standard 3. _ The following dollar amount: $ __ _ Note: If this amount changes, this iteiTI will be revised. Approval Date OCT 2 '1 2012 Effective Date Feb /)) ;J/) e 1: l 1:

SUPPLEMENT 4 TO ATTACHMENT 3.1-A Page4 OMB No.: 0939-0193 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State/Territory: Nebraska 4. The following percentage of the following standard that is not greater than the standards above: __ % of standard. 5. The amount is determined using the following formula: 6. Not applicable (N/A) (C.) Family (check one): 1 . AFDC need standard 2. _ Medically needy income standard The amount specified below cannot exceed the higher of the need standard for a family of the same size used to determine eligibility under the State's approved AFDC plan or the medically needy income standard established under 435.811 for a family of the same size. 3. _ The following dollar amount: $ __ _ Note: If this amount changes, this item will be revised. 4. The following percentage of the following standard that is not greater than the standards above: % of standard. 5. The amount is determined using the following formula: 6. Other 7. Not applicable (N/A) (b) Medical and remedial care expenses specified in 42 CFR 435.735. Spousal Post Eligibility 3.___x_ State uses the post-eligibility rules of Section 1924 of the Act (spousal impoverishment protection) to determine the individual's contribution toward the cost of PACE services if it determines the individual's eligibility under section 1924 of the Act. There shall be deducted from the individual's monthly income a personal needs allowance (as specified below), and a community spouse's allowance, a family allowance, and an amount for incurred expenses for medical or remedial care, as specified in the State Medicaid plan. (a.) Allowances for the needs of the: 1. Individual (check one) TN No. NE 12-04 Supersedes TN No. New page (A). _ The following standard included under the State plan (check one): 1. SSI 2. Medically Needy 3. _ The special income level for the institutionalized 4. _ Percent of the Federal Poverty Level: __ 5. _ Other (specify): _________ _ Approval Date OCT 2 l! 2012 Effective Date Feb 0/ ~{))3

Q,eu \cSru S-<biY\icss'o"" 9.;;;) t. I';) SUPPLEMENT 4 TO ATTACHMENT 3.1-A Page 5 OMB No.: 0939-0193 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State/Territory: Nebraska (B). _The following dollar amount: $ ___ _ Note: If this amount changes, this item will be revised. (C) . ..1$_ The following formula is used to determine the needs allowance: (1) For waiver clients receiving Assisted Living Services: The State protects the SSI standard. (2) For clients receiving waiver services in other eligible living arrangements: The State protects the medically needy income standard. If this amount is different than the amount used for the individual's maintenance allowance under 42 CFR 435.726 or 42 CFR 435.735, explain why you believe that this amount is reasonable to meet the individual's maintenance needs in the community: II. Rates and Payments A. The State assures that the capitated rates will be equal to or less than the cost to the agency of providing those same fee-for-service State plan approved services on a fee-for-service basis, to an equivalent non-enrolled population group based upon the following methodology. Please attach a description of the negotiated rate setting methodology and how the State will ensure that rates are less than the cost in fee- for-service. 1. 2. 3. 4. _1L Rates are set at a percent of fee-for-service costs Experience-based (contractors/State's cost experience or encounter date)(please describe) Adjusted Community Rate (please describe) Other (please describe) Rates are set at a percent of Upper Payment Limits. The State contracts with an actuarial company to develop PACE Upper Payment Limits (UPLs). The UPLs are developed based on historical Nebraska Medicaid fee- for-service (FFS) costs for individuals aged 55 and over who were either nursing home residents or eligible for HCBS waiver services based on meeting nursing facility level of care criteria. Projection factors are applied to the UPLs to reflect utilization changes, historical and prospective Medicaid program changes, and provider rate changes. The UPLs are then summarized into rate cells by eligibility category and defined geographic area. The State ensures that rates paid to PACE provider organizations are less than the cost in FFS by negotiating a rate for each rate cell set at 95% of the UPL for that cell. TN No. NE 12-04 Supersedes TN No. New page Approval Date · OCT 2 '! 2012 Effective Date Feb bJ eJIJ)..3

SUPPLEMENT 4 TO ATTACHMENT 3.1-A Page6 OMB No.: 0939-0193 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State/Territory: Nebraska B. The State Medicaid Agency assures that the rates were set in a reasonable and predictable manner. Please list the name, organizational affiliation of any actuary used, and attestation/description for the initial capitation rates. The State contracted with Milliman, Inc., to develop its initial UPLs for calendar year 2012. The initial UPLs were developed by Shelly S. Brandel, FSA, MAAA, Actuary, and David F. Ogden, FSA, MAAA, Principal and Consulting Actuary. The UPLs are an estimate of what costs would have been to Nebraska Medicaid for PACE participants if they had not enrolled in PACE. Within each eligibility category (dually Medicaid and Medicare eligible, Medicaid only, and dually Medicaid and Medicare (Part B only} eligible}, Milliman developed separate UPLs for nursing home residents and HCBS waiver participants who meet nursing facility level of care criteria (aka PACE eligibles) by geographic area. Milliman then weighted these UPLS by the estimated distribution of individuals in each service category (based on the distribution of 2009 eligible months) to calculate the overall UPLs. The distribution of individual~ for Part B only eligibles was assumed to be the same as for dual eligibles. Data Reliance and Important Caveats In developing the UPLs, Milliman relied on data and other information provided by the State. Since the source of the data was the State's Medicaid Management Information System (MMIS), the State takes responsibility for the accuracy and validity of the base data. The following data and information was used: • Medicaid claims and eligibility data for individuals ages 55 and older, including a description of each data field and its potential use in classifying individuals into eligibility groupings of service use and Medicare eligibility; • Summary of Medicaid fee and program changes in SFY 2008 and later; and • Quarterly CMS-64 Medicaid Administrative Cost reports for SFY 2010. Base Data and Adjustments The State provided claims and eligibility data for Medicaid individuals ages 55 and over for the period January 1, 2007, through the most recent date available at the time, August, 2010. 1 . Excluded Data Milliman excluded the following data: TN No. NE 12-04 Supersedes TN No. New page ·OCT 2 ,t 2012 Approval Date - Effective Date Feb {)) r:JIJJ.3

SUPPLEMENT 4 TO ATTACHMENT 3.1-A Page 7 OMB No.: 0939-0193 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State/Territory: Nebraska • Managed care enrollees; • Partial Medicare eligibility: Claims and eligibility data for individuals with partial Medicare eligibility (Part A or Part B only) were excluded. (Note: Milliman developed UPLs for Part B only eligibles based on the projected results for Medicaid only and dual eligibles due to a small number of individuals in the data with Part B only eligibility.) • Individuals with claims but no eligibility; and • Claims and eligibility for individuals for whom the county of residence was outside the State of Nebraska. 2. UPL Categories Milliman separated the data into eligibility groupings or "cells" as follows: • Dual eligible versus Medicaid only; • Nursing home residents versus HCBS waiver participants; and • Urban versus rural geographic areas. Regarding Medicare eligibility, individuals with full Medicare coverage (Part A and B) or no Medicare coverage were included in the analysis. As noted above, individuals with partial Medicare coverage (Part A or Part 8 only) were excluded from the analysis (Part B only UPL projections are based on the UPL results for Medicaid only and dual eligibles due to the small number of Part B only individuals in the data.) Nursing home residents were flagged as such for each month within each individual's total eligibility segment(s) if the total nursing home payments for the month were greater than $0.00. If an individual was identified as both a nursing home resident and a HCBS waiver participant for a given month, the individual was classified by Milliman as a nursing home resident for purposes of their analysis. Milliman classified data as "rural" or "urban" based on the county of residence in the eligibility file as follows: Urban: Douglas, Lancaster, Gage, Otoe, Saline, Sarpy, Saunders, Seward, and Washington counties (counties surrounding Omaha and Lincoln, Nebraska); and Rural: Remaining counties in Nebraska. TN No. NE 12-04 Supersedes TN No. New page Approval Date , OCT 2 •1 2 12 Effective Date Feb () 1 ~tJJ3 .,

SUPPLEMENT 4 TO ATTACHMENT 3.1-A Page 8 OMB No.: 0939-0193 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT StatefT erritory: Nebraska 3. Data Adjustments The following were taken into consideration regarding the claims and eligibility data, and adjustments were made as appropriate: • Disproportionate Share Hospital (DSH) payments; • Critical Access Hospitals; • Graduate Medical Education (GME); • Federally Qualified Health Center (FQHC)/Rural Health Clinic (RHC) payments; • Third Party Liability (TPL); • Copayments; • Organ Transplants; • Prescription Drug Rebates; • Historical Program Changes: The base experience data was adjusted to reflect historical Medicaid program changes that became effective during the experience period. The program changes include: o CHIP eligibility to 100% of the Federal Poverty Limit (9/1/2009 o Hospital Inpatient DRG Reimbursement Structure (1 0/1/2009); and o Radiology Management (11/1/2009); and • Claims Completion Factors. PACE UPL Development Milliman used 2009 experience as a base to project a UPL for CY 2012. They applied the following projection factors to project 2009 experience for each rate category to CY 2012: • Trend factors; • Prospective Nebraska Medicaid program changes; • Prospective provider rate changes; and • PACE administrative costs. TN No. NE 12-04 Supersedes TN No. New page Approval Date , OCT 2 ~1 2012 Effective Date Feb bJ c20J3

'* . SUPPLEMENT 4 TO ATTACHMENT 3.1-A Page 9 OMB No. : 0939-0193 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT Statefferritory: Nebraska 1. Trend Factors Milliman developed the trend factors by reviewing the following information: • Historical trends from 2007 to 2009 for the PACE eligibles in the data; • Information about changes in the Nebraska Medicaid program (historical and projected) to better understand provider fee and program changes during the experience period to interpret non-fee based trends; and • Knowledge about Medicaid trends in other states and Medicare trends for representative service categories. 2. Prospective Medicaid Program Changes Milliman adjusted the PACE UPLs to reflect the impact of Nebraska Medicaid program changes taking place between the experience period (CY 2009) and the projection period (CY 2012). They relied on Mercer's Data Book dated December 1, 2009, to estimate the appropriate adjustment for each program change which includes: • Facility/Non-Facility pricing; and • Outpatient Hospital Cost Ratio decrease. 3. Prospective Provider Rate Changes The PACE UPL projections reflect the following anticipated future changes to Nebraska Medicaid provider payment rates: • A 0.5% rate increase for all services effective for SFY 2011 beginning on July 1, 2010). • A 5% rate decrease for all services except primary care for SFY 2012 and SFY 2013. - Note the following regarding future Medicaid provider rate changes: • Milliman assumed that Medicaid provider rate changes would have no impact on pharmacy costs. Therefore, the provider rate change factor for pharmacy services was 1.000. TN No. NE 12-04 Supersedes TN No. New page Effective Date feb tJ) .2Pl3 1.

TN No. New page SUPPLEMENT 4 TO ATTACHMENT 3.1-A Page 10 OMB No.: 0939-0193 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State/Territory: Nebraska • Although the FFS data did not indicate primary care versus specialty care services, Milliman expected the level of primary care services in the PACE population to be very small given the amount of chronic care services. Therefore they did not make an adjustment to the SFY 2012 and SFY 2013 Medicare rate decreases to exclude primary care services. • For dual eligibles, the impact of Medicaid provider rate changes is difficult to predict since a significant amount of costs for many services are paid by Medicare. Milliman assumed the Medicaid provider rate change increases would be dampened by a factor of %for dual eligibles for the following services: inpatient hospital; outpatient hospital; physician; other practitioner; radiology and laboratory; clinic; DME/supplies; and transportation. 4. PACE Administrative Costs Milliman added a 3.9% allowance (as a percentage of projected 2012 claims) for PACE administrative services based on the CMS-64 data the State provided for SFY 2010. The CMS 64 reports reflect the State's current Medicaid administrative costs as a percentage of claim payments. School-based administrative costs were excluded from the calculation. There were very few individuals in the FFS with Part 8 only Medicare eligibility, therefore the historical data was not credible for purposes of UPL development. Milliman calculated the Part B only UPLs by setting the projected 2012 UPL for each service category equal to either the dual eligible UPL or the Medicaid only UPL. They linked the following service categories to the dual eligible UPL (meaning they expected that Medicare coverage would decrease the expected costs PEPM for Part B eligibles): outpatient hospital; physician; other practitioner; radiology and laboratory; clinic; pharmacy; DME/supplies; and transportation. All other service categories were linked to the Medicaid only UPL. C. The State will submit all capitated rates to the CMS Regional Office for prior approvaL TN No. NE 12-04 Supersedes TN No. New page Effective Date Feb IJJ :Jtll3 ; · i· I I· ~ ' I j. i· I I I f ,.

SUPPLEMENT 4 TO ATTACHMENT 3.1-A Page 11 OMB No.: 0939-0193 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT · StatefTerritory: Nebraska Ill. Enrollment and Disenrollment The State assures that there is a process in place to provide for dissemination of enrollment and disenrollment data between the State and the State Administering Agency. The State assures that it has developed and will implement procedures for the enrollment and disenrollment of participants in the State's management information system, including procedures for any.adjustment to account for the difference between the estimated number of participants on which the prospective monthly payment was based and the actual number of participants in that month. TN No. NE 12-04 Supersedes TN No. New page Approval DateOCT 2 ~ t 2n1? Effective Date ftd> 6) .Jil/3 j.'

Revision: HCFA-PM-94-9 (MB) ATTACHMENT 3.1-B Page 8b December 1994 StatefTerritory: Nebraska AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED MEDICALLY NEEDY GROUP(S): All groups 25. Home and Community Care for Functionally Disabled Elderly Individuals. as defined, described and limited in Supplement 2 to Attachment 3.1-A, and Appendices A-G to Supplement 2 to Attachment 3.1-A. [8J Provided D Not Provided 26. Personal assistance services are those services provided to a Medicaid client who is not an inpatient or resident of a hospital, nursing facility, intermediate cafe facility for the mentally retarded, institution for mental disease, or prison, which are authorized on a written service plan according to individual needs identified in a written assessment. Personal assistance services are A) authorized by a Social Services Worker or designee, B) provided by qualified providers who are not legally responsible relatives, and C) are furnished inside the home, and outside the home with limitations [8J Provided ~ State Approved (Not Physician) Service Plan Allowed [8J Services Outside the Home Also Allowed* [8J Limitations Described on Attachment D Not Provided 27. Program of All-Inclusive Care for the Elderly (PACE) services, as described in Supplement 4 to Attachment 3.1-A. ..X.. Election of PACE: By virtue of this submittal, the State elects PACE as an optional State Plan service. No election of PACE: By virtue of this submittal, the State elects to not add PACE as an optional State Plan service. 28. (i) Licensed or Otherwise State-Approved Freestanding Birth Centers Provided: 0 No Limitations [8J With Limitations 0 None licensed or approved . D Not Applicable (there are no licensed or State approved Freestanding Birth Centers Please describe any limitations: Facilities must: (a) Be specifically approved by Department of Health and Human Services, Division of Public Health to .provide birthing Center Services, and (b) Maintain standards of care required by Department of Health and Human Services, Division of Public Health for licensure. * Exception described on attachment TN No. NE 12-04 Supersedes Approval Date ' OCT 2 11 2012 Effective Date Feb IJ J ..2 tJ 13 TN No. 11-21 · .. ·. . . . · .. · .

Revision: HCFA-PM-94-9 December 1994 State!T erritory: Nebraska (MB) ATTACHMENT 3.1 -B Page 8c AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED MEDICALLY NEEDY GROUP(S): All groups 28. (ii) Licensed or OtheiWise Sate-Recognized covered professionals providing services in the Freestanding Birth Centers Provided: 0 No Limitations ~ With Limitations (please describe below) Please check all that apply: ~ (a) Practitioners furnishing mandatory services described in another benefit category and othe!Wise covered under the Sate plan (i.e., physicians and certified nurse midwives. D (b) Other licensed practitioners furnishing prenatal, labor and delivery, or postpartum care in a freestanding birth center within the scope of practice under State law whose services are otheiWise covered under 42 CFR 440.60 (e.g., lay midwives, certified professional midwives (CPMs), and any other type of licensed midwife).* D (c) Other health care professionals licensed or othe!Wise recognized by the State to provide these birth attendant services (e.g., doulas, lactation consultant, etc.).* TN No. NE 12-04 Supersedes TN No. NE 11-21 . OCT 2 ~1 2012 Approval Date Effective Date Feb 01 O)tJl3 ,, 1 .

--- ------~ DEPARTMENT OF HEALTH AND HUMAN SERVICES HEALTH CARE FINANCING ADMINISTRATION TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: HEALTH CARE FINANCING ADMINISTRATION TO: REGIONAL ADMINISTRATOR HEALTH CARE FINANCING ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One): 1. TRANSMITTAL NUMBER: 12-04 FORM APPROVED OMB NO. 0938-0193 2. STATE Nebraska 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) 4. PROPOSED EFFECTIVE DATE February 1, 2013 0 NEW STATE PLAN 0 AMENDMENT TO BE CONSIDERED AS NEW PLAN 1:8] AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT Se arate Transmittal or each amendment 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: a. FFY 2013 $(34,684) b. FFY 2014 $(131 ,927) 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION Section 3, pp19c and 20c Attachment 2.2-A, p 11 Attachment 3 .1-A, p 10 and 1 Oa Supplement 4 to Attachment 3 .1-A, pp 1-11 Attachment 3 .1-B, p 8b, 8c 10. SUBJECT OF AMENDMENT: OR ATTACHMENT (If Applicable): Attachment 2.2-A, p 11 Attachment 3.1-A, p 10 and lOa Attachment 3.1-B, p 8b, 8c Implemenation of Program of All-Inclusive Care for the Elderly (PACE) 11. GOVERNOR'S REVIEW (Check One): 12. 0 GOVERNOR'S OFFICE REPORTED NO COMMENT 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED 0 NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 16. ----,-,,.....-::::~~~~~~~-1.~......;!~:.-AM~~-----~ Nancy Keller 1:8] OTHER, AS SPECIFIED: Governor has waived review TO: Division of Medicaid & Long-Term Care ....,-,:--==:::::=::=c.:....::...c::..c....::..::.:..c.=c:..::.:..:.----------------1 Nebraska Department of Health & Human Services Term Care 301 Centennial Mall South ,.~~:;y;-;;-;r,:;u:r;::;;:;;rn:=-:------....,_ _______ ----1 Lincoln, NE 68509 FORMHCFA-179 (07-92) /s/

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services 601 East 12th Street, Suite 355 Kansas City, Missouri 64106

Division of Medicaid and Children's Health Operations

April 26, 2013

Vivianne Chaumont, Director Department of Health & Human Services Division of Medicaid and Long Term Care 301 Centennial Mall S., 5th Floor PO Box 95026 Lincoln, Nebraska 68509

Dear Ms. Chaumont:

On September 26, 2012, the Centers for Medicare & Medicaid Services (CMS) received Nebraska’s State Plan Amendment (SPA) transmittal #12-007, which proposes to increase the fee schedule rates for clinical diagnostic laboratory services and injectable medications by 1.5% with a proposed effective date of July 1, 2012.

This SPA 12-007 was approved on April 25, 2013, with an effective date of July 1, 2012, as requested by the state. Enclosed is a copy of the CMS-179 form, as well as, the approved pages for incorporation into the Nebraska State Plan.

If you have any questions regarding this amendment, please contact Narinder Singh at (816) 426-5925 or Narinder.Singh@cms.hhs.gov.

Sincerely,

James G. Scott

Associate Regional Administrator

for Medicaid and Children’s Health Operations

Enclosure

cc: Nancy Keller bcc: Megan Buck

Sandra Levels

Rhonda Wells

Christopher Resler

Alexandra Smilow

Cynthia Ruff

Narinder Singh

Asher Mikow

Douglas Thomas

Myrika Awoyera

Revised Sub mission .2013.03.20

ATTACHMENT 4.19-B Item 3, Page 2

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State Nebraska

METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES

Clinical Diagnostic Laboratory Services

Payment for clinical diagnostic laboratory services, including collection of laboratory specimens by venipuncture or catheterization, is paid at 99% of the fee schedule determined by Medicare.

X-Ray Services

For dates of service on or after August 1, 1989, NMAP pays a claim for both the technical and professional components of x-ray services at the lower of:

1. 2.

The provider's submitted charge; or

The allowable amount for that procedure code in the Nebraska Medicaid Practitioner Fee Schedule in effect for that date of service. The allowable amount is indicated in the fee schedule as -

The unit value multiplied by the conversion factor;

The invoice cost (indicated as "IC" in the fee schedule);

The maximum allowable dollar amount; or

The reasonable charge for the procedure as determined by the Medicaid Division (indicated as "BR" - by report or "RNE" - rate not established - in the fee schedule).

2009

The Nebraska Medicaid Practitioner Fee Schedule is effective July 1 through June 30 of each

year.

Revisions of the Fee Schedule: The Department reserves the right to adjust the fee schedule to:

1.

Comply with changes in state or federal requirements;

2. Comply with changes in nationaliy-recognized coding systems, as HCPCS and CPT; 3. Establish an initial allowable amount for a new procedure based on information that was not available when the fee schedule was established for the current year; and 4, Adjust the allowable amount when the Medicaid Division determines that the current allowable amount is: a. Not appropriate for the service provided; or b. Based on errors in data or calculation. TN #. NE 12-07 7 Supersedes Approval Date APR 25 2013 Effective Date! JUL. 0 | 2012

TN#. NE 11-25

Rev i. ‘sed Submission of. 7.13

ATTACHMENT 4.19-B Item 4b, Page 1

STATE PLAN UNDER TITLE X!X OF THE SOCIAL SECURITY ACT State Nebraska

METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES

EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT) SERVICES For EPSDT services provided on or after April 1, 1990, the following applies.

For services reimbursed under the Nebraska Medicaid Practitioner Fee Schedule, NMAP pays for EPSDT services (except for clinical diagnostic laboratory services) at the lower of:

1. The provider's submitted charge; or

2. The allowable amount for that procedure code in the Nebraska Medicaid Practitioner Fee Schedule for that date of service. The allowable amount is indicated in the fee schedule as -

The unit value multiplied by the conversion factor;

The invoice cost (indicated as "IC" in the fee schedule);

The maximum allowable dollar amount; or

The reasonable charge for the procedure as determined by the Medicaid

Division (indicated as "BR’ - by report or "RNE’ - rate not established in the fee

schedule).

ae79

The Nebraska Medicaid Practitioner Fee Schedule is effective July 1 through June 30 of each year.

TN #, NE 12-07 Supersedes Approval Date APR 25 2013

TN #. NE 14-25

Effective Date JUL 9 1 2072

Revised Submission 2.7/3

ATTACHMENT 4.19-B Item 5, Page 2

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State Nebraska

METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES

Revisions of the Fee Schedule: The Department reserves the right to adjust the fee schedule to:

Comply with changes in state or federal requirements;

Comply with changes in nationaily-recagnized coding systems, such as HCPCS and CPT; Establish an initial allowable amount for a new procedure based on information that was not available when the fee schedule was established for the current year; and

Adjust the allowable amount when the Medicaid Division determines that the current allowable amount is:

a. Not appropriate for the service provided: or

b. Based on errors in data or calculation.

Oya

The Department may issue revisions of the Nebraska Medicaid Practitioner Fee Schedule during the year that it is effective. Providers will be notified of the revisions and their effective dates.

SMOKING CESSATION

Smoking cessation services rendered via common procedural terminology (CPT) codes 99406 and 99407 are reimbursed on a fee schedule.

Payment for Telehealth Services: Payment for telehealth services is set at the Medicaid rate for the comparable in-person service.

Payment for Telehealth Transmission Costs: Payment for telehealth transmission costs is set at the lower of: (1) the provider's submitted charge; or (2) the maximum allowable amount.

The Department reimburses transmission costs for line charges when directly related to a covered telehealth service. The transmission must be in compliance with the quality standards for real time, two way interactive audiovisual transmission as set forth in state regulations, as amended.

TN #. NE 12-07 ane Supersedes Approval Date _ APR 25 2013 Effective Date JUL. Qin

TN #. NE 10-08

Revised Submission 2.7/3

ATTACHMENT 4.19-B Item 6a, Page 1

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State Nebraska

METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES

PODIATRISTS' SERVICES

NMAP pays for covered podiatry services at the lower of:

1. The provider's submitted charge; or

2. The allowable amount for that procedure code in the Nebraska Medicaid Practitioner Fee Schedule in effect for that date of service. The allowable amount is indicated in the fee schedule as: a. The unit value multiplied by the conversion factor; b. The invoice cost (indicated as "IC" in the fee schedule); c. The maximum allowable dollar amount; d. The reasonable charge for the procedure as determined by the Medicaid Division

(indicated as "BR" - by report or "RNE" - rate nat established - in the fee schedule).

Revisions of the Fee Schedule: The Department may adjust the fee schedule to:

1. Comply with changes in state or federal requirements;

2. Comply with changes in nationally-recognized coding systems, such as HCPCS and CPT;

3. Establish an initial allowable amount for a new procedure or a procedure that was previously identified as “"RNE" or "BR" based on information that was not available when the fee schedule was established for the current year; and

4, Adjust the allowable amount when the Medicaid Division determines that the current allowable amount is:

a. Not appropriate for the service provided; or b. Based on errors in data or calculation.

™ #. NE 12-07 . Supersedes Approval Date APR 25 2013 Effective Date JU] Of 77? TN #. NE 11-25

Revised Submission 2.7/3

ATTACHMENT 4.19-B Item 6a, Page 2

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State Nebraska METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES

Providers will be notified of changes and their effective dates.

Payment for Telehealth Services: Payment for telehealth services is set at the Medicaid rate for the comparable in-person service.

Payment for Telehealth Transmission Costs: Payment for teleheaith transmission costs is set at the lower of: (1) the provider's submitted charge; or (2) the maximum allowable amount.

The Department reimburses transmission costs for line charges when directly related to a covered teleheaith service. The transmission must be in compliance with the quality standards for real time, two way interactive audiovisual transmission as set forth in state regulations, as amended. i

TN#. NE 12-07 : oy mae NE 12-07 du 1 4 Supersedes Approval Date APR 2S 2018 Effective Date ein *

TN #. MS-00-06

“Revised Sadmission a7/3

ATTACHMENT 4,19-B Item 6b, Page 1

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State Nebraska METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES

OPTOMETRISTS' SERVICES

NMAP pays for covered optometrists' services at the lower of:

1. The provider's submitted charge; or 2. The allowable amount for that procedure code in the Nebraska Medicaid Practitioner Fee

Schedule in effect for that date of service. The allowable amount is indicated in the fee

schedule as:

a. The unit value multiplied by the conversion factor,

b. The invoice cost (indicated as "IC" in the fee schedule) - the provider's actual cost (including discounts) from the provider's supplier. The maximum invoice cost payable is limited to reasonable available cost:

The maximum allowabie dollar amount; or The reasonable charge for the procedure as determined by the Medicaid Division (indicated as "BR" - by report or "RNE" - rate not established - in the fee schedule).

29

Revisions of the Fee Schedule; The Department may adjust the fee schedule to:

1. Comply with changes in state or federal requirements;

2. Comply with changes in nationally-recognized coding systems, such as HCPCS and CPT;

3. Establish an initial allowable amount for a new procedure or a procedure that was previously identified as "RNE" of "BR" based on information that was not available when the fee schedule was established for the current year; and

4. Adjust the allowable amount when the Medicaid Division determines that the current allowable amount is:

a. Not appropriate for the service provided; or b. Based on errors in data or calculation.

Providers will be notified of changes and their effective dates.

TN #. NE 12-07 Supersedes Approval Date APR 25 2013 Effective Date

TN #. NE 11-25

FE

Revised Submission A213

ATTACHMENT 4.19-B . Item 9, Page 2

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State Nebraska

METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES

Payment for Psychiatric Day Treatment Services: Payment rates for psychiatric day treatment services for individuals age 19 and older will be on a unit basis. Rates are set annuatly for the period July 1 through June 30. Rates are set prospectively for this period and are not adjusted during the rate period. Providers are required to report their costs on an annual basis. Providers desiring to enter the program who have not previously reported their costs or that are newly Operated are to submit a budgeted cost report, estimating their anticipated annual costs.

Providers shall submit cost and statistical data on the required form based on the timeframes in 471 NAC 20-003.08. Providers shall compile data based on generally accepted accounting principles and the actual method of accounting based on the provider's fiscal year. Financial and statistical records for the period covered by the cost report must be accurate and sufficiently detailed to substantiate the data reported. If the provider fails to file a cost report as due, the Department will suspend payment. At the time the suspension is imposed, the Department will inform the provider via letter that no further payment will be made until a proper cost report is filed. In setting payment rates, the Department will consider those costs which are reasonable and necessary for the active treatment of the clients being served. Such costs will include those necessary for licensure and accreditation, meeting ail staffing standards for participation, meeting all service standards for participation, meeting ail requirements for active treatment, maintaining medical records, conducting utilization review, meeting inspection of care requirements, and discharge planning. The Department does not guarantee that all costs will be reimbursed. The cost reporting document is used by the Department only as a guide in the rate setting process. Actuai costs incurred by the providers may not be entirely reimbursed.

Psychiatric day treatment centers operated by the State of Nebraska will be reimbursed for all reasonable and necessary costs of operation, excluding educational services. State-operated centers will receive an interim payment rate, with an adjustment to actual costs following the cost reporting period.

TN #. NE 12-07 APR 25 2019 Supersedes Approval Date Effective Date jj) Q4 77 "" TN #. MS-00-06

Revised Submission 2.7 i3 ATTACHMENT 4.19-B Item 12d STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State Nebraska

METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES

EYEGLASSES NMAP pays for covered eyeglasses at the lower of:

1. The provider's submitted charge; or 2 The allowable amount for that procedure code in the Nebraska Medicaid

Practitioner Fee Schedule in effect for that date of service. The allowable amount

is indicated in the fee schedule as:

a. The unit value multiplied by the conversion factor;

b. The invoice cost (indicated as "IC" in the fee schedule) - the provider's actual cost (including discounts) from the provider's supplier. The maximum invoice cost payable is limited to reasonable available cost;

Cc. The maximum allowable dollar amount; or

d. The reasonable charge for the procedure as determined by the Medicaid Division (indicated as “BR" by report or "RNE" rate not established in the fee schedule).

Revisions of the Fee Schedule: The Department may adjust the fee schedule to:

1, | Comply with changes in state or federal requirements;

2. Comply with changes in nationally-recognized coding systems, such as HCPCS and CPT;

3. Establish an initial allowable amount for a new procedure or a procedure that was previously identified as "RNE" or "BR" based on information that was not available when the fee schedule was established for the current year; and

4. Adjust the allowable amount when the Medicaid Division determines that the current allowable amount is:

a. Not appropriate for the service provided; or b. Based on errors in data or calculation.

Providers will be notified of changes and their effective dates.

TN#. NE 12-07 Supersedes Approval Date APR ZS 2013

TN #. NE 11-25

Effective Date

Revised Submission 02713

ATTACHMENT 4.19-B ltem 20, Page 1 of 2

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State Nebraska METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES

EXTENDED SERVICES TO PREGNANT WOMEN

For dates of service on or after August 1, 1989, NMAP pays for extended services to pregnant women at the lower of:

1. The provider's submitted charge; or 2. The allowable amount for that procedure code in the Nebraska Medicaid Practitioner Fee Schedule in effect for that date of service. The allowable amount is indicated in the fee schedule as: a. The unit value multiplied by the conversion factor, b. The invoice cost (indicated as “IC" in the fee schedule); c. The maximum allowable dollar amount; or d. The reasonable charge for the procedure as determined by the Medicaid Division (indicated as "BR" - by report or "RNE" - rate not established - in the fee schedule).

The Nebraska Medicaid Practitioner Fee Schedule is effective July 1 through June 30 of each year.

Revisions of the Fee Schedule: The Department reserves the right to adjust the fee schedule to:

1. Comply with changes in state or federal requirements;

2. Comply with changes in nationally-recognized coding systems, such as HCPCS and CPT;

3. Establish an initial allowable amount for a new procedure based on information that was not available when the fee schedule was established for the current year, and

4. Adjust the allowable amount when the Medicaid Division determines that the current allowable amount is: a. Not appropriate for the service provided; or b. Based on errors in data or calculation,

The Department may issue revisions of the Nebraska Medicaid Practitioner Fee Schedule during the year that itis effective. Providers will be notified of the revisions and their effective dates.

TN#. NE 12-07 wn

TN #. MS-00-06

{ omy

Supersedes Approval Date _ APR 25 2013 Effective Date 7) iL ~-

Revised Submission 2.713

ATTACHMENT 4.19-B Item 21, Page t of 2

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State Nebraska

METHODS

AND STANDARDS FOR ESTABLISHING PAYMENT RATES

AMBULATORY PRENATAL CARE FOR PREGNANT WOMEN FURNISHED DURING A

PRESUMPTIVE ELIGIBILITY PERIOD

For dates of service on or after August 1, 1989, NMAP pays for ambulatory prenatal care for pregnant women furnished during a presumptive eligibility period by a Medicaid-enrolled provider at the lower of:

1. 2.

The provider's submitted charge; or

The allowable amount for that procedure code in the Nebraska Medicaid Practitioner

Fee Schedule in effect for that date of service. The allowable amount is indicated in

the fee schedule as:

a. The unit value multiplied by the factor;

Db. The invoice cost (indicated as "IC" in the fee schedule);

c. The maximum allowable dollar amount; or

d. The reasonable charge for the procedure as determined by the Medicaid Division (indicated as "BR" - by report or "RNE" - rate not established - in the fee schedule).

The Nebraska Medicaid Practitioner Fee Schedule is effective July 1 through June 30 of each year.

Revisions of the Fee Schedule: The Department reserves the right to adjust the fee schedule to:

1.

Comply with changes in state or federal requirements;

2. Comply with changes in nationally-recognized coding systems, such as HCPCS and CPT; 3. Establish an initial allowable amount for a new procedure based on information that was not available when the fee schedule was established for the current year, and 4. Adjust the allowable amount when the Medicaid Division determines that the current allowable amount is: a. Not appropriate for the service provided; or b. Based on errors in data or calculation. TN #. NE 12-07 ay nen Supersedes Approval Date APR25 2013 Effective Date t's VY ob yes

TN #. MS-00-06

* Item 3, Page 2 * Item 3, Page 2 September 26, 2012 * Pen and Ink change per e-mail from state dated 3.20.13. April 25, 2013 July 1, 2012 James G. Scott Associate Regional Administrator for Medicaid and Children's Health Operations /s/

DEPARTMENT OF HEALTH & HUMAN SERVICES ~ Centers for Medicare & Medicaid Services

7500 Security Boulevard, Mail Stop S2-26-12 < M Ss Baltimore, Maryland 21244-1850

CENTERS FOR MEDICARE & MEDICAID SERVICES CENTER FOR MEDICAID & CHIP SERVICES

Center for Medicaid and CHIP Services

APR 3 2013

Vivianne M. Chaumont, Director

Division of Medicaid and Long-Term Care Nebraska Department of Health and Human Services 301 Centennial Mall South

Lincoln, Nebraska 68509

RE: Nebraska State Plan Amendment TN: 12-09 Dear Ms. Chaumont:

We have reviewed the proposed amendment to Attachment 4.19-A of your Medicaid State plan submitted under transmittal number (TN) 12-09. This amendment provides for a 1.5 percent rate increase for children’s inpatient hospital psychiatric services and adult sub-acute inpatient hospital psychiatric services.

We conducted our review of your submittal according to the statutory requirements at sections 1902(a)(2), 1902(a)(13), 1902(a)(30), 1903(a) and 1923 of the Social Security Act and the implementing Federal regulations at 42 CFR 447 Subpart C. This is to inform you that Medicaid State plan amendment 12-09 is approved effective July 1, 2012. We are enclosing the HCFA-179 and the amended plan pages.

If you have any questions, please call Tim Weidler at (816) 426-6429. ely,

fa Dany 6

Cindy Mann Director Center for Medicaid and CHIP Services

Enclosures

ATTACHMENT 4.19-A Page 16

10-010.03D Payments for Psychiatric Services: Payments for psychiatric discharges are made on a prospective per diem.

Tiered rates will be used for all acute psychiatric inpatient services. This includes services provided at a facility enrolled as a provider for psychiatric services which is not a licensed psychiatric hospital or a Medicare-certified distinct part unit. Payment for each discharge equals the applicable per diem rate times the number of approved patient days for each tier.

Payment is made for the day of admission, but not the day of discharge.

10-010.03D1 For payment of inpatient hospital psychiatric services, effective July 1, 2012, the tiered per diem rate will be:

Days of Service Per Diem Rate Days 1 and 2 $683.93 Days 3 and 4 $632.21 Days § and 6 $603.48 Days 7 and greater $574.74

10-010.03E Payments for Rehabilitation Services: Payments for rehabilitation discharges are made on a prospective per diem.

All rehabilitation services, regardless of the type of hospital providing the service, will be reimbursed on a per diem basis. This includes services provided at a facility enrolled as a provider for rehabilitation services which is not a licensed rehabilitation hospital or a Medicare-certified distinct part unit. The per diem will be the sum of -

1. The hospital-specific base payment per diem rate; 2. The hospital-specific capital per diem rate; and 3. The hospital's direct medical education per diem rate, if applicable.

Payment for each discharge equals the per diem times the number of approved patient days.

Payment is made for the day of admission but not for the day of discharge.

TN No. NE 12-09

Supersedes

TN No. 41-43

APR 3 2013 Approved Effective =} 2049

ATTAGHMENT 4.19-A Page 17a

10-010.03D5 Payment for Psychiatric Adult Inpatient Subacute Hospital Services: Payments for psychiatric adult inpatient subacute hospital services are

- made on a per diem basis. This rate may be reviewed annuaily. Effective April 12, 2008, the payment for psychiatric adult subacute inpatient hospital services identified in state regulations was $488.13. Beginning July 1, 2008, the per diem tate was $505.21 and on November 24, 2009 onward the rate is $512.79. On July 1, 2010, there will be a .5% rate increase. On July 1, 2011, there will be a 2.5% rate decrease. On July 1, 2012 there is a 1.54% increase. The subacute impatient hospital per diem rate is not a tiered rate. Payment will be an all inclusive per diem, with the exception of physician services.

TN# NE 12-09 ye 2 Supersedes Approved APR 3 201) Ettective JJL ~ = TN # NE 11-26

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION OMB NO. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF 1, TRANSMITTAL NUMBER: 2. STATE STATE PLAN MATERIAL 12-09 Nebraska

FOR: HEALTH CARE FINANCING ADMINISTRATION

3, PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID)

TO: REGIONAL ADMINISTRATOR HEALTH CARE FINANCING ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES

4, PROPOSED EFFECTIVE DATE July 1, 2012

§. TYPE OF PLAN MATERIAL {Check One): (1) NEW STATE PLAN

( AMENDMENT TO BE CONSIDERED AS NEW PLAN

AMENDMENT

COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment)

6. FEDERAL STATUTE/REGULATION CITATION:

8, PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

Attachment 4.19-A, page 16 and 17a

7, FEDERAL BUDGET IMPACT: a. FFY 2012 $367,150 b. FFY 2013 $1,468,598

9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (ff Applicable):

Attachment 4.19-A, page 16 and 17a

10, SUBJECT OF AMENDMENT: Children's Mental Health & Substance Abuse Rate Change

11. GOVERNOR’S REVIEW (Check One): [1] GOVERNOR'S OFFICE REPORTED NO COMMENT L. COMMENTS OF GOVERNOR'S OFFICE ENCLOSED _ [I NOREPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

OTHER, AS SPECIFIED: Governor has waived review

12. SI ATURE OF STATE AGENCY OFFICJAL: anus WU,

13, TYPED NAME: Vivianne M, Chaumont

14, TITLE: Director, Division of Medicaid and Long-Term Care

16, RETURN TO:

Nancy Keller

Division of Medicaid & Long-Term Care Nebraska Department of Health & Human Services 301 Centennial Mall South

15. DATE SUBMITTED: ember 20, 2012

Lincoln, NE 68509

FORM HCFA-179 (07-92)

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services 601 East 12th Street, Suite 355 Kansas City, Missouri 64106

Division of Medicaid and Children's Health Operations

December 4, 2012

Vivianne Chaumont, Director Department of Health & Human Services Division of Medicaid and Long Term Care 301 Centennial Mall S., 5th Floor PO Box 95026 Lincoln, Nebraska 68509

Dear Ms. Chaumont:

On September 20, 2012, the Centers for Medicare & Medicaid Services (CMS) received Nebraska’s State Plan Amendment (SPA) transmittal #12-010, which proposes to amend the fee schedule rates for children’s mental health and substance abuse services with a proposed effective date of July 1, 2012.

This SPA 12-010 was approved on November 30, 2012, with an effective date of July 1, 2012, as requested by the State. Enclosed is a copy of the CMS-179 form, as well as, the approved page for incorporation into the Nebraska State plan.

If you have any questions regarding this amendment, please contact Narinder Singh at (816) 426-5925 or Narinder.Singh@cms.hhs.gov.

Sincerely,

/s/

James G. Scott

Associate Regional Administrator

for Medicaid and Children’s Health Operations

Enclosure

cc: Nancy Keller

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: Nebraska METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES Other Licensed Practitioners: Licensed Alcohol and Drug Counselor (LADC) Attachment 4.19-B Item 4b, Page 3 Rehabilitation Services - 42 CFR 440.130(d): Day Treatment/Intensive Outpatient Service by Direct Care Staff; Community Treatment Aide; Professional Resource Family Care; and Therapeutic Group Home Reimbursement for services is based upon a Medicaid fee schedule established by the State of Nebraska. Except as otherwise noted in the Plan, the State-developed fee schedule is the same for both governmental and private individual practitioners and the fee schedule and any annual/periodic adjustments to the fee schedule are published at http://dhhs.ne.gov/medicaid/Pages/med provhome.aspx (Division of Medicaid and Long-Term Care website). The above mentioned fee schedule is applicable to all services reimbursed via a fee schedule. The agency's rates were set as of July 1, 2012 and are effective for services provided on or after that date. The Nebraska Medicaid fee schedule outlined above will be established using the following methodologies: • If a Medicare fee exists for a defined covered procedure code, then Nebraska will set the Nebraska Medicaid fee schedule for LADC at 95 percent of the licensed Master's level rate paid under Attachment 3.1A, Item 6d for any codes permitted under their scope of practice per Nebraska state law. • Where Medicare fees do not exist for a covered code, the fee schedule will be set using a market-based pricing methodology as described below. These reimbursement methodologies will produce rates sufficient to enlist enough providers so that services under the Plan are available to individuals at least to the extent that these services are available to the general population, as required by 42 CFR 447.204. These rates comply with the requirements of Section 1902(a)(30) of the Social Security Act 42 CFR 447.200, regarding payments and consistent with economy, efficiency and quality of care. Provider enrollment and retention will be reviewed periodically to ensure that access to care and adequacy of payments are maintained. The Medicaid fee schedule will be equal to or less than the maximum allowable under the same Medicare rate, where there is a comparable Medicare rate. Room and board costs are not included in the Medicaid fee schedule. The market-based pricing methodology will be composed of provider cost modeling for four key components: direct care salary expenses, employee related expenses, program indirect expenses and administrative expenses. The analysis includes national compensation studies for Nebraska to determine the appropriate wage or salary expense for the direct care worker providing each service based on the staffing requirements and roles and responsibilities of the worker, published information related to employee related expenses and other notable cost components and cost data and fees from similar State Medicaid programs. The following list outlines the major components of the cost model to be used in fee development: (1) Staffing Assumptions and Staff Wages (2) Employee-Related Expenses- Benefits, Employer Taxes (e.g., FICA, unemployment, and workers compensation) (3) Program-Related Expenses (e.g., supplies) (4) Provider Overhead Expenses (5) Program Billable Units The fee schedule rates will be developed as the ratio of total annual modeled provider costs to the estimated annual billable units. TN# NE 12-10 Supersedes TN# 11-10 Approved NOV 3 0 2012 Effective Date ----=-~...::... ·~ :._=--0_1_ 2012 1- ! I· i

DEPARTMENT OF HEALTH AND HUMAN SERV!t:;ES HEALTH CARE FINANCING ADMINISTRATION TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: HEALTH CARE FINANCING ADMINISTRATION TO: REGIONAL ADMINISTRATOR HEALTH CARE FINANCING ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One): I. TRANSMITTAL Nl,JMBER: 12-10 FORM APPROVED OMB NO. 0938-0193 2. STATE Nebraska 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) 4. PROPOSED EFFECTIVE DATE July 1,2012 0 NEW STATE PLAN 0 AMENDMENT TO BE CONSIDERED AS NEW PLAN cgj AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT Se arate Transmittal or each amendment 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: a. FFY 2012 $367,150 b. FFY 2013 $1,468,598 8. PAGE NUMBER OF THE PLAN SECTION OR A ITACHMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION Attachment 4.19-B, Item 4b, page 3 I 0. SUBJECT OF AMENDMENT: Children's Mental Health & Substance Abuse Rate Change 11. GOVERNOR'S REVIEW (Check One): . 0 GOVERNOR'S OFFICE REPORTED NO COMMENT 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED 0 NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMIITAL 12. OR ATTACHMENT (If Applicable): Attachment 4.19-B, Item 4b, page 3 cgj OTHER, AS SPECIFIED: Governor has waived review 16. RETURN TO: ---::-:=-=~~~~~~_:_:~~~~~~m4-----~ Nancy Keller 13. Division of Medicaid & Long-Term Care -::-:--:::::==.:==:==.=...::;::..::==.::.:....---------------l Nebraska Department of Health & Human Services 3 0 I Centennial Mall South Director Division of Medicaid and Term Care ---;-;~~~~~~~~==..;::::::c:;..=;:..:=_::_;:c;..:::.....::..::.:..:.._ ___ -1 Lincoln, NE 68509 FORM HCFA-179 (07-92)

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services , 7500 Security Boulevard, Mail Stop $2-26-12 . . ¢ “€ vv Ss Baltimore, Maryland 21244-1850 CENTERS FOR MEDICARE & MEDICAID SERVICES CENTER FOR MEDICAID & CHIP SERVICES

Center for Medicaid and CHIP Services (CMCS)

Vivianne M. Chaumont, Director :

Division of Medicaid and Long-Term Care SEP 19 2012 Nebraska Department of Health and Human Services

301 Centennial Mall South

Lincoln, Nebraska 68509

RE: Nebraska State Plan Amendment TN: 12-11 Dear Ms. Chaumont:

We have reviewed the proposed amendment to Attachment 4.19-D of your Medicaid State plan submitted under transmittal number (TN) 12-011. This amendment increases the nursing facility (NF) reimbursement rate for hospital and therapeutic leave days (bedhold) from the rate that is in effect for assisted living services under the Home and Community-Based (HCBS) Aged & Disabled waiver to the full NF per diem rate. The rate increase is effective for service dates in April and May 2012.

We conducted our review of your submittal according to the statutory requirements at sections 1902(a)(13), 1902(a)(30), and 1903(a) of the Social Security Act and the implementing Federal regulations at 42 CFR 447 Subpart C. This is to inform you that Medicaid State plan amendment 12- 011 is approved effective April 1, 2012. We are enclosing the HCFA-179 and the amended plan pages.

If you have any questions, please call Tim Weidler at (816) 426-6429. Sincerely,

Foo Pap be

eh M Director, CMCS

Enclosures

ATTACHMENT 4.19-C STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State Nebraska

BEDHOLDING

The Nebraska Medical Assistance Program makes payments to reserve a bed in a nursing facility (NF) or an intermediate care facility for the mentally retarded (ICF/MR) during a client's absence due to hospitalization for an acute condition and for therapeutically-indicated home visits. Therapeuticaily-indicated home visits are ovemight visits with relatives and friends or visits to participate in therapeutic or rehabilitative, programs. Payment for bedholding is subject to the following conditions:

1. A held bed must be vacant and counted in the census. The census must not exceed licensed capacity;

2. For ICF/MR residents, hospital bedhoiding is limited to full per diem reimbursement for 16 days per hospitalization (hospital bedholding does not apply to hospital NF- swing-beds or fo hospitalization following a Medicare-covered (SNF) stay);

3. For NF residents, except for the months of April and May of 2012 in which payment is at full per diem reimbursement, hospital bedholding is limited to reimbursement at the applicable rate in effect for assisted living services under the Home and Community-Based Waiver for Aged Persons and Adults or Children with Disabilities for 15.days per hospitalization (hospital bedholding does not apply to hospital NF-swing-beds or to hospitalization following a Medicare-covered (SNF) stay);

4. For ICFIMR residents, therapeutic bedholding is limited to full per diem reimbursement for 36 days per calendar year.

5. For NF residents, except for the months of April and May of 2012 in which payment is. at full per diem reimbursement, therapeutic feave bedhalding is limited to the applicable rate in effect for assisted living services under the Home and Community-Based Waiver for Aged Persons and Adults or Children with Disabilities for 18 days per calendar year. Bedholding days are prorated when a client is admitted after January 1;

6. A transfer from one facility to another does not begin a new 18-day or 36-day period;

7. The client's comprehensive care plan must provide for therapeutic leave; and

8. Facility staff shail work with the client, the client's family and/or guardian to plan the use of the allowed 18 days of therapeutic leave for the calendar year.

When the limitation for therapeutic leave interferes with an approved therapeutic or rehabilitation program, the facility may submit a request for special limits of up to an additional six days per calendar year to the Medical Services Division.

TN # NE 12-14 | Supersedes Approval DateSEP 1 9 2012 Effective Date APR ~1 2012

TN # NE 12-01

ATTACHMENT 4.19-D Page 2

Rate Payment means per diem rates paid under provisions of 471 NAC 12-011.08. The payment-rate for Levels of Care 101, 102, 103 104 and 105 is the applicable rate in effect for assisted living services under the Home and Community-Based Waiver Services for Aged Persons or Adults or Children with Disabilities (see 480 NAC 5). Except the payment for level of care 105 (bed-hold) for the months of April and May 2012 is the applicable payment rate as determined under 471 NAC 12-011.08.

Revisit Fees means fees. charged to health care facilities by the Secretary of Health and Human Services to cover the costs incurred under Department of Health and Human Services, Centers for Medicare and Medicaid Services, Program Management’ for conducting revisit surveys on health care facilities cited for deficiencies during initial certification, recertification or substantiated complaint surveys.

Urban means Douglas, Lancaster, Sarpy, and Washington Counties.

Waivered Facility means facilities for which the State Certification Agency has waived professional nurse staffing requirements of OBRA 87 are classified as “waivered" if the total number of waivered days exceeds 90 calendar days at any time during the reporting period.

Weighted Resident Days means a facility's inpatient days, as adjusted for the acuity level of the residents in that facility,

Other definitions which. apply in this section are included in Nebraska Department of Health and Human Services Division ef Public Heaith's regulations in Title 175, Chapter 12, Skilled Nursing Facitities, Nursing Facilities, and Intermediate Care Facilities and appropriate federal regulations governing Title XIX and Title XVII.

12-011.03 General Information: Wherever applicable, the principles of reimbursement far provider's cost and the related policies under which the Medicare extended care facility program functions (Medicare's Provider Reimbursement. Manual (HIM-15) updated by “Provider Reimbursement Manual Revisions" in effect as of July 1, 2009 are used in determining the cost for Nebraska nursing facilities with exceptions noted in this section. Chapter 15, Change of Ownership, of HIM- 18 is excluded in its entirety. So ne That portion of a provider's allowable cost for the treatment of Medicaid patients is payable under the Nebraska Medical Assistance Program (Medicaid) except as limited In this section. The aggregate payments by the Department do not exceed amounts which would be paid under Title XVI principles of reimbursement for extended care facilities.

Except for IHS nursing facility providers, a provider with 1,000 or fewer Medicaid inpatient days during a complete fiscal year Report Period (see 471 NAC 12-011.088) will not file a cost report. The rate paid will be based on the average base rate components, effective July 1 of the rate period of all other providers in the same care classification, following the initial desk audits.

12-011.04 Allowable Costs: The following items are allowable costs under Medicaid. 12-011.04A Cost of Meeting Licensure and Certification Standards: Allowable costs for

meeting licensure and certification standards are those costs incurred in order to:

Meet the definition and requirements for a Nursing Facility of Title XIX of the Social ‘Security Act, Section 1919;

TN# NE 12-11 P 2012 ; Supersedes Approved SEP 19 Effective _APR -4 2012

TN# NE 12-02

ATTACHMENT 4.19-D Page 15a

12-011.08E Exception Process: An individual facility may request, on an exception basis, the Director of the Division of Medicaid and Long-Term Care to consider specific facility clreumstance(s), which warrant an exception to the facility's rate computed for its Fixed Cost Component. An exception may only be requested if the facility's total fixed costs (total costs, not per diem rate), as compared to the immediately prior report period, have increased by ten percent or more. In addition, the facility's request must include:

1. Specific identification of the increased cost(s) that have caused the facility's total fixed costs to increase by 10 percent or more, with justification for the reasonableness and necessity of the increase;

2. Whether the cost increase(s) are an ongoing or a one-time occurrence in the cost of operating the facility; and

3. If applicable, preventive management action that was implemented to. control past and future cause(s) of identified cost Increase(s).

12-011.08F ment for Levels of Care 101, 102, 103, 104 and 105: Rates as determined for Levels of Care 101, 102, 103 and 104 under the cost-based prospective

‘ methodology of 471 NAC 12-011.08A through 12-011.08E may be adjusted for actual payment. Level of Care 105 is used for payment of qualifying bedhold days. The payment rate for Levels of Care 101, 102, 103,104 and 105 is the applicable rate In effect for assisted living services under the Home and Community-Based Waiver Services for Aged Persons or Adults or Children with Disabilities (see 480 NAC 5), © Except the payment for level of care 105 (bed-hold) for the months of April and May 2012 is the applicable payment rate as determined under 471 NAC 12-011.08.

12-011.08G Out-of-State Facilities: The Department pays out-of-state facilities participating in Medicaid at a rate established by that state's Medicaid program at the

time of the issuance or reissuance of the provider agreements. The payment is not subject to any type of adjustment.

TN# NE 12-14 Supersedes Approved SEP 19 2012 Effective _APR -1 2012

TN# NE 12-02

OS Notification State/Title/Plan Number: NE 12-011 Type of Action: SPA Approval Required Date for State Notification: 09/20/2012

Fiscal Impact: FY 2012 $156,114 FY 2013 $ -0-

Number of Services Provided by Enhanced Coverage, Benefits or Retained Enrollment: 0

Number of Potential Newly Eligible People: 0

Eligibility Simplification: No

Provider Payment Increase: No

Delivery System Innovation: No Number of People Losing Medicaid Eligibility: 0 Reduces Benefits: No

Detail:

Effective for services in April and May 2012, this amendment increases the nursing facility (NF) reimbursement rate for hospital and therapeutic leave days (bedhold), from the rate that is in effect for assisted living services under the HCBS Aged & Disabled waiver to the full NF per diem rate.

In a prior amendment (SPA 12-02) the State had reduced the bedhold rate from the NF per diem to the assisted living rate effective January 15,2012. Subsequent to approval of SPA 12-02, the State decided they didn’t want to fully implement the rate reduction until June 1, 2012. They therefore submitted this amendment to permit a rate increase for the months of April and May 2012. Effective June 1, 2012, the bedhold rate will return to the assisted living rate.

Public notice and tribal consultation requirements were met for this SPA. The

bedhold payments are funded by appropriations. The funding questions were answered acceptably.

Other Considerations: There has been no expressed interest from the

Governor’s Office, Congressional staff, or other outside parties.

CMS Contact: Tim Weidler, NIRT 816-426-6429

DEPARTMENT Of HEALTH AND HUMAN SERVICES HEALTH CARE FINANCING ADMINISTRATION

FORM APPROVED OMB NO. 0938-0193

TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL

FOR: HEALTH CARE FINANCING ADMINISTRATION

2, STATE Nebraska

1. TRANSMITTAL NUMBER: 12-11

3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID)

TO: REGIONAL ADMINISTRATOR HEALTH CARE FINANCING ADMINISTRATION

DEPARTMENT OF HEALTH AND HUMAN SERVICES

4. PROPOSED EFFECTIVE DATE April 1, 2012

5. TYPE OF PLAN MATERIAL (Check Ong): [J NEW STATE PLAN

(1 AMENDMENT TO BE CONSIDERED AS NEW PLAN

& AMENDMENT

7. FEDERAL BUDGET IMPACT: a. FFY 2012 $(156,114) b. FFY 2013 30

8, PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

Attachment 4.19-C Attachment 4.19-D, Page 2 and [Sa

9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (if dppticable):

Attachment 4.19-C Attachme ot 4.19-D, Page 2 and 15a

10, SUBJECT OF AMENDMENT: Payment for Nursing Facilities Leave Days

U1. GOVERNOR'S REVIEW (Check One): (] GOVERNOR'S OFFICE REPORTED NO COMMENT (] COMMENTS OF GOVERNOR'S OFFICE ENCLOSED ([] NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

[ OTHER, AS SPECIFIED: Governor has waived review

12. SI NATURE OF STATE AGENCY OFFICIAL:

OMML YL.

16, RETURN TO:

13, TYPED NAME: Vivianne M. Chaumont

Nancy Keller

14, TITLE: Director, Division of Medicaid and Long-Term Care

15. DATE SUBMITTED: 2012

— FOR REGIONAL OFFICE USE ONLY

17. DATE RECEIVED:

SEP 19 2012

18. DATE APPROVED:

PLAN APPROVED — ONE COPY ATTACHED _-

FFE! TIVE DATE OF APPROVED MATERIAL: 19. EFFEC :

| 20. SIGNA’ OF REGIONAL OFFICIAL: penye~

21, TYPED NAME: Aun Thom Osont T WV

Py Divcene, Cmes ‘ \

23, REMARKS:

FORM HCFA-179 (07-92)

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services 601 East 12th Street, Suite 355 Kansas City, Missouri 64106

Division of Medicaid and Children's Health Operations

November 19, 2012

Vivianne Chaumont, Director Department of Health & Human Services Division of Medicaid and Long Term Care 301 Centennial Mall S., 5th Floor PO Box 95026 Lincoln, Nebraska 68509

Dear Ms. Chaumont:

On August 10, 2012, the Centers for Medicare & Medicaid Services (CMS) received Nebraska’s State Plan Amendment (SPA) transmittal #12-013, which proposes to increase the fee schedule rate by 1.5% with a proposed effective date of July 1, 2012.

This SPA 12-013 was approved on November 5, 2012, with an effective date of July 1, 2012, as requested by the State. Enclosed is a copy of the CMS-179 form, as well as, the approved page for incorporation into the Nebraska State plan.

If you have any questions regarding this amendment, please contact Narinder Singh at (816) 426-5925 or Narinder.Singh@cms.hhs.gov.

Sincerely,

/s/

James G. Scott

Associate Regional Administrator

for Medicaid and Children’s Health Operations

Enclosure

cc: Nancy Keller

Revised Submission &. 3112

ATTACHMENT 4.19-B Item 1

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State Nebraska

Except as otherwise noted in the plan, state developed fee schedule rates are the same for both government and private providers and the fee schedule and any annual/periodic adjustments to the fee schedule are published at htto://dhhs.ne.gov/medicaid/Pages/med_provhome.aspx {Division of Medicaid and Long-Term Care website). The above mentioned fee schedule is applicable to all services reimbursed via a fee schedule. The agency's rates were set as of July 1, 2012 and are effective for services on or after that date.

TN No. NE 12-13 NoY 0 5 2012

Supersedes Approval Date TN No.. NE 11-28

Effective DateJUL 0 1 2012

Revised Stubwnissipn 8.31.12

ATTACHMENT 4.19-B Item 5, Page 1 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State Nebraska

METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES

PHYSICIANS’ SERVICES

For dates of service on or after August 1, 1989, NMAP pays for covered physicians' services at the lower of: 1. The provider's submitted charge; or 2. The allowable amount for that procedure code in the Nebraska Medicaid Practitioner Fee Schedule in effect for that date of service. The allowable amount is indicated in the fee schedule as: a. The unit value multiplied by the conversion factor (last updated on July 1, 2010); b. The invoice cost (indicated as “IC" in the fee schedule); or c. The reasonable charge for the procedure as determined by the Medicaid Division (indicated as "BR" - by report or "RNE" - rate not established - in the fee schedule). 3. Exception: The Director of the Division of Medicaid and Long-Term Care or designee may enter into an agreement for a negotiated rate with an out-of-state provider which will be based on a percentage of billed charges, not to exceed 100%, only when the Medical Director of the Division has determined that: a. The client requires specialized services that are not available in Nebraska; and b. No other source of the specialized service can be found.

The following is a listing of specialized physician services that have been previously rendered by out-of-state providers:

a. lung transplants; and

b. pediatric heart transplants.

Note: The above listing is not all-inclusive of the specialized physician services that will be reimbursed via negotiated rates in the future, as it is based on previous experience.”

The Nebraska Medicaid Practitioner Fee Schedule was last updated on July 1, 2012 and is effective for services rendered on or after that date. The fee schedule is subject to annual/periodic adjustment. All rates, including current and prior rates, are published and maintained on the agency's website. Specifically, the fee schedule and any annual/periadic adjustments to the fee schedule are published at

http:/Awww.dhhs.ne.gov/medicaid/Pages/med_practitioner_fee schedule. aspx.

Physicians and non-physician care providers are subject to a site-of-service payment adjustment. A site-of-service differential that reduces the fee schedule amount for specific CPT/HCPCS codes will be applied when the service is provided in the facility setting. Based on the Medicare differential, NMAP will reimburse specific CPT/HCPCS codes with adjusted rates based on the site-of-service.

The Nebraska Medicaid Practitioner Fee Schedule is effective July 1 through June 30 of each year.

TN #, 12-13

Supersedes Approval Date NOY 05 2012 Effective Date ‘JUL 0 1 2012

TN #.NE 11-19

Revised Submisson §.3).12

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION OMB NO, 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF 1. TRANSMITTAL NUMBER: 2. STATE STATE PLAN MATERIAL 12-13 Nebraska

FOR: HEALTH CARE FINANCING ADMINISTRATION

3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID)

TO: REGIONAL ADMINISTRATOR HEALTH CARE FINANCING ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES

4, PROPOSED EFFECTIVE DATE FAN2

5, TYPE OF PLAN MATERIAL (Check One):

(1 NEW STATE PLAN

(] AMENDMENT TO BE CONSIDERED AS NEW PLAN

f] AMENDMENT

COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment)

6. FEDERAL STATUTE/REGULATION CITATION:

7. FEDERAL BUDGET IMPACT: a. FFY 2012 $70,325 b. FFY 2013 $281,298

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

Attachment 4.19-B, Item 1 Attachment 4.19-B item 5, p}

9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (ff Applicable):

Attachment 4.19-B, Item 1 Attachment 4.19-B Item 5, p1

10. SUBJECT OF AMENDMENT: Fee Schedule Rate Update

11, GOVERNOR'S REVIEW (Check One): (1 GOVERNOR’S OFFICE REPORTED NO COMMENT [1 COMMENTS OF GOVERNOR’S OFFICE ENCLOSED [NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

[x] OTHER, AS SPECIFIED: Governor has waived review

12. Mibu OF STATE A CY OFFI AL:

16. RETURN TO:

13. TYPED NAME: Vivianne M. Chaumont

Nancy Keller Division of Medicaid & Long-Term Care

14. TITLE: Director, Division of Medicaid and Long-Term Care

Nebraska Department of Health & Human Services 301 Centennial Mall South

15. DATE SUBMITTED: August 10, 2012

Lincoln, NE 68509

FORM HCFA-179 (07-92}

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services 601 East 12th Street, Suite 355 Kansas City, Missouri 64106

Division of Medicaid and Children's Health Operations

March 12, 2013

Vivianne Chaumont, Director Department of Health & Human Services Division of Medicaid and Long Term Care 301 Centennial Mall S., 5th Floor PO Box 95026 Lincoln, Nebraska 68509

Dear Ms. Chaumont:

On August 20, 2012, the Centers for Medicare & Medicaid Services (CMS) received Nebraska’s State Plan Amendment (SPA) transmittal #12-017, which proposes to increase the fee schedule rates for outpatient hospital services by 1.5% with a proposed effective date of July 1, 2012.

SPA 12-017 was approved on March 11, 2013, with an effective date of July 1, 2012, as requested by the state. Enclosed is a copy of the CMS-179 form, as well as, the approved pages for incorporation into the Nebraska State Plan.

If you have any questions regarding this amendment, please contact Narinder Singh at (816) 426-5925 or Narinder.Singh@cms.hhs.gov.

Sincerely,

/s/

Leticia Barraza

Acting Associate Regional Administrator

for Medicaid and Children’s Health Operations

Enclosure

cc: Nancy Keller

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State Nebraska ATTACHMENT 4.19-8 Item 2a, Page 1 METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES . Payment for Outpatient Hospital and Emergency Room Services: For services provided on or after July 1 I 2012, the Department pays for outpatient hospital and emergency services with a rate which is the product of: 1. Seventy four percent (74%) of the cost-to-charges ratio from the hospital's latest Medicare cost report (Form CMS-2552-89, Pub. 15-11, Worksheet C); multiplied by 2. The hospital's submitted charges on Form CMS-1450 (UB-04). The effective date of the cost-to-charges percentage is the first day of the month following the Department's receipt of the cost report. Providers shall bill outpatient hospital and emergency room services on Form CMS-1450 (UB- 04) in a summary bill format. Providers shall not exceed their usual and customary charges to non-Medicaid patients when billing the Department. Exception: All outpatient clinical laboratory services must be itemized and identified with the appropriate HCPCS procedure codes. The Department pays for clinical laboratory services based on ninety nine percent (99%) of the fee schedule determined by Medicare. Payment for Outpatient Hospital and Emergency Room Services Provided by Critical Access Hospitals: Effective for cost reporting periods beginning after July 1 I 2012, payment for outpatient services of a CAH is ninety nine percent (99%) of the reasonable cost of providing the services, as determined under applicable Medicare principles of reimbursement, except that the following principles do not apply: the lesser of costs or charges (LCC) rule and the reasonable compensation equivalent (RCE) limits for physician services to providers. NMAP will adjust interim payments to reflect elimination of any fee schedule methods for specific services, such as laboratory or radiology services, that were previously paid for under those methods. Payment for these and other outpatient services will be made in at ninety nine percent (99%) of the reasonable cost of providing the services. Professional services must be billed by the physician or practitioner using the appropriate physician/practitioner provider number, not the facility's provider number. To avoid any interruption of payment, NMAP will retain and continue to bill under existing provider numbers until new CAH numbers are assigned. TN No. 12-17 Supersedes TN No. 11-23 Approval Date MAR f110fj Effective Date JVL 0 1 2Dl2

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State Nebraska METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES ATIACHMENT 4.19-B Item 2a, Page 2 Payment to Hospital-Affiliated Ambulatory Surgical Centers: The Department pays for services provided in an HAASC according to Payment for Outpatient Hospital and Emergency Room Services, unless the HAASC is a Medicare-participating ambulatory surgical center (ASC). If the HAASC is a Medicare-participating ASC, payment is made at the rate established by Medicaid for the appropriate group of procedures. Approval of Payment for Emergency Room Services: At least one of the following conditions must be met before the Department approves payment for use of an emergency room: 1. The patient is evaluated or treated for a medical emergency, accident, or injury (see definition of medical emergency in NAG 1 0-001.02); 2. The patient's evaluation or treatment in the emergency room results in an approved inpatient hospital admission (the emergency room charges must be displayed on the inpatient claim as charges and included in the inpatient per diem); or 3. The patient is referred by a physician such as for allergy shots or when traveling (a written referral by the physician must be attached to the claim); The facility should review emergency room services and determine whether services provided in the emergency room constitute an emergency and bill accordingly. When the facility or the Department determine services are non-emergent, the room fee for non-emergent services provided in an emergency room will be disallowed to 50 percent of the applicable ratio of cost-to-charges. All other Medicaid allowable charges incurred in this type visit will be paid at seventy four percent (74%) of the ratio of cost-to-charges. Diagnostic and Therapeutic Services: The payment rate for diagnostic and therapeutic services includes payment for services required to provide the service. Extra charges, such as stat fees, call-back fees, specimen handling fees, etc., are considered administrative expenses and are included in the payment rate. Payment to a New Hospital for Outpatient Services: See the definition of a new operational facility in 471 NAC 10-010.03A. Payment to a new hospital (a operational facility) will be made at seventy four percent (74%) of the statewide average ratio of cost to charges for Nebraska hospitals as of July 1 of that year as determined by the Department. This payment is retrospective for the first reporting period for the facility. This ratio will be used until the Department receives the hospital's initial cost report. The Department shall cost-settle claims for Medicaid-covered services which are paid by the Department using seventy four percent (74%) of the statewide average ratio of cost to charges. The cost settlement will be the lower of cost or charges as reflected on the hospital's cost report (i.e., the Department's payment must not exceed the upper limit of the provider's charges for services). TN No. 12-17 Supersedes TN No. 11-23 Approval Date HAR 1 1 2013 Effective Date _J_UL._ 0_1_2DtZ

ATTACHMENT 4.19-B Item 2a, Page 3 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State Nebraska METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES Upon the Department's receipt of the hospital's initial Medicare cost report, the Department shall no longer consider the hospital to be a "new hospital" for payment of outpatient services. The Department shall determine the ratio of cost to charges from the initial cost report and shall use that ratio to prospectively pay for outpatient services. (For a complete description of payment for outpatient services, see 471 NAC 10-010.06 ff.) Payment to An Out-of-State Hospital for Outpatient Services: Payment to an out-of-state hospital for outpatient services will be made based on the statewide average ratio of cost to charges times seventy four percent (74%) for all Nebraska hospitals for that fiscal year as of July 1 of that year. Payment for Telehealth Services: Payment for telehealth services is set at the Medicaid rate for the comparable in-person service. Payment for Telehealth Transmission Costs: Payment for telehealth transmission costs is set at the lower of: (1) the provider's submitted charge; or (2) the maximum allowable amount. The Department reimburses transmission costs for the line charges when directly related to a covered telehealth service. The transmission must be in compliance with the quality standards for real time, two-way interactive audio-visual transmission as set forth in state regulations, as amended. TN No. 12-17 Supersedes TN No. 11-23 HAR 1 1 2013 Approval Date ____ _ Effective Date JUL O 1 Z!Jll -----

DEPARTMENT OF HEALTH AND HUMAN SERVICES HEALTH CARE FINANCING ADMINISTRATION TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: HEALTH CARE FINANCING ADMINISTRATION TO: REGIONAL ADMINISTRATOR HEALTH CARE FINANCING ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One): 1. TRANSMITTAL NUMBER: 12-17 FORM APPROVED OMB NO. 0938-0193 2. STATE Nebraska 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) 4. PROPOSED EFFECTIVE DATE July 1, 2012 0 NEW STATE PLAN 0 AMENDMENT TO BE CONSIDERED AS NEW PLAN [8J AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT 'Se arate Transmittal or each amendment 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: a. FFY 2012 $263,823 b. FFY 2013 $1,055,292 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION Attaclunent 4.19-B, Item 2a, Page 1, 2 and 3 10. SUBJECT OF AMENDMENT: Outpatient Hospital Rate Increase 11. GOVERNOR' S REVIEW (Check One): 12. 0 GOVERNOR'S OFFICE REPORTED NO COMMENT 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED 0 NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL OR ATTACHMENT (If Applicable): Attachment 4.19-B, Item 2a, Page 1, 2 and 3 [81 OTHER, AS SPECIFIED: Governor has waived review 16. RETURN TO: -;:~~~~~~~~~~~~~~~~L-----j Nancy Keller 13· Division of Medicaid & Long-Term Care -~..:.:,:.:::::::~=-===:..:::.:..--------------1 Nebraska Department of Health & Human Services 301 Centennial Mall South Term Care ~~~~~~~~~~~~~~~~~~----~ Lmcom,NE68509 FORM HCFA-179 (07-92) /s/

DEPARTMENT OF HEALTH & HUMAN SERVICES - Centers for Medicare & Medicaid Services

7500 Security Boulevard, Mail Stop S2-26-12 < M S Baltimore, Maryland 21244-1850

CENTERS FOR MEDICARE & MEDICAID SERVICES CENTER FOR MEDICAID & CHIP SERVICES

Center for Medicaid and CHIP Services

APR -3 2013

Vivianne M. Chaumont, Director

Division of Medicaid and Long-Term Care Nebraska Department of Health and Human Services 301 Centennial Mall South

Lincoln, Nebraska 68509

RE: Nebraska State Plan Amendment TN: 12-18 Dear Ms. Chaumont:

We have reviewed the proposed amendment to Attachments 4.19-A of your Medicaid State plan submitted under transmittal number (TN) 12-18. This amendment provides for a 1.5 percent rate increase for all acute care inpatient hospital services.

We conducted our review of your submittal according to the statutory requirements at sections 1902(a)(2), 1902(a)(13), 1902(a)(30), 1903(a) and 1923 of the Social Security Act and the implementing Federal regulations at 42 CFR 447 Subpart C. This is to inform you that Medicaid State plan amendment 12-18 is approved effective July 1, 2012. We are enclosing the HCFA-179 and the amended plan pages.

If you have any questions, please call Tim Weidler at (816) 426-6429. Sincerely,

fen Mayr. h

Cindy Mann Director Center for Medicaid and CHIP Services

Enclosures

ATTACHMENT 4.19-A

Page 5 40-010.03B1b Calculation of Nebraska Peer Group Base Payment Amounts:

Peer Group Base Payment Amounts are used to calculate payments for discharges with a stable DRG. Peer Group Base Payment Amounts effective October 1, 2009 are calculated for Peer Group 1, 2 and 3 hospitals based on the Peer Group Base Payment Amounts effective during SFY 2007, adjusted for budget neutrality, calculated as follows:

4. Peer Group 1 Base Payment Amounts, Excluding Children's Hospitals: Multiply the SFY 2007 Peer Group 1 Base Payment Amount of $3,844.00 by the Stable DRG budget neutrality factor.

2. Children's Hospital Peer Group 1 Base Payment Amounts, Excluding Children's Hospitals: Multiply the SFY 2007 Children's Hospital Peer Group 1 Base Payment Amount of $4,614.00 by the Stable DRG budget neutrality factor.

3. Peer Group 2 Base Payment Amounts: Multiply the SFY 2007 Peer Group 2 Base Payment Amount of $3,733.00 by the Stable DRG budget neutrality factor.

4. Peer Group 3 Base Payment Amounts: Multiply the SFY 2007 Peer Group 3 Base Payment Amount of $3,535.00 by the Stable DRG budget neutrality factor.

SFY 2007 Nebraska Peer Group Base Payment Amounts are described in 471 NAC 10-010.03B4 in effect on September 1, 2007 and 471 NAC 10-010.03B in effect on July 1, 2001.

Peer Group Base Payment Amounts will be increased by 0.5% for the rate period beginning October 1, 2009 and ending June 30, 2010. This rate increase will not be carried forward in subsequent years. Peer Group Base Payment Amounts excluding the 0.5% increase for the rate period beginning October 1, 2009 and ending June 30, 2010, will be increased by .5% for the rate period beginning July 1, 2010. The Peer Group Base Payment Amount effective July 1, 2070 will be

reduced by 2.5% effective July 1, 2011. The Peer Group Base Payment Amount ffective Jul 2011 wil 4% effective July 1, 2012.

Transmittal # 12-18

Supersedes

APR -3 2013 7 Approved, Etfectidvi © 1 2012

Transmittal # 11-22

ATTACHMENT 4,18-A

Page 6 10-010.03B2__ Calculation of Stable DRG Cost Outlier Payment Amounts:

Additional payment is made for approved discharges classified into a stable DRG meeting or exceeding Medicaid criteria for cost outliers for each stable DRG

- classification. Cost outliers may be subject to medical review.

Discharges qualify as cost outliers when the costs of the service exceed the outiler threshold. The outlier threshold is the sum of the operating cost payment amount, the indirect medical education amount, and the capital-related cost payment amount, plus $51,800. Cost of the discharge is calculated by multiplying the Medicaid allowed charges by the sum of the hospital specific Medicare operating and capital outlier CCRs. Additional payment for cost outliers is 80% of the difference between the hospital's cost for the discharge and the outlier threshold for all discharges except for burn discharges, which will be paid at 85%.

10-010.0382a Hospital Specific Medicare Outlier CCRs: The Department will extract from the CMS PPS Inpatient Pricer Program the hospital-specific

Medicare operating and capital outlier CCRs effective October 4 of the year preceding the start of the Nebraska rate year. For rates effective October 1, 2009, the Department will extract the outlier CCRs effective in the Medicare system on October 1, 2008.

40-010.03B2b Outlier CCRs Updates: On July 1 of each year, the Department will update the outlier CCRs based on the Medicare outlier

CCRs effective October 1 of the previous year.

Transmittal # 12-18 APR -3 2019

Supersedes

Jai - 12012 Approved Effective

Transmittal # 411-22

ATTACHMENT 4.19-A Page 8

June 30, 2009, will be increased by .5% for the rate period beginning July 1, 2010. Effective July 1, 2011, the direct medical education amount shall be

reduced by 2.5 percent. Effective July 1, 2012, the direct medical education unt si increased b rcent.

10-01 B3b_ Calculation le DRG Indirect Medical Education (IME. Cost Payments: Hospitals qualify for IME payments when they receive a direct medical education payment from NMAP, and qualify for indirect medical education payments from Medicare. Recognition of indirect medical education costs incurred by hospitals are an add-on calculated by multiplying an IME factor by the operating cost payment amount.

The IME factor is the Medicare inpatient prospective payment system operating IME factor effective October 1 of the year preceding the beginning of the Nebraska rate year. The operating IME factor shalt be determined using data extracted from the CMS PPS Inpatient Pricer Program. For rates effective October 1, 2009, the Department will determine the operating IME factors effective for the Medicare system on October 1, 2008 using the following formula:

-[(4+(Number of Interns and Residents/Available Beds)}9-405.4) * 1.35

On July 1* of each year, the Department will adopt the Medicare inpatient prospective payment system operating IME factor formulas and rate components in effect on October 1 of the previous year.

10-010.033B3¢_ Calculation of MCO Medical Education Payments: NMAP will calculate annual MCO Direct Medical Education payments and MCO

Indirect Medical Education payments for services provided by NMMCP capitated plans from discharge data provided by the hospital. MCO Direct Medical Education payments will be equal to the number of MCO discharges times the MCO direct medical education payment per discharge. The MCO direct medical education payment per discharge is the hospital- specific fee-for-service DME payment rates for stable DRGs, unstable or low volume DRGs and transplant DRGs in effect for the rate year July 1 through June 30.

Transmittal # 12-18 Supersedes

Transmittal # 11-22

ATTACHMENT 4.19-A Page 10

40-010,03B4 Calculation of Stable DRG Capital-Related Cost Payment: Capltal- related cost payments for the building and fixtures portion of capital-related costs are paid on a per discharge basis for stable DRGs. Per discharge amounis are calculated by multiplying the capital per diem cost by the statewide average length-oi-stay for the stable DRG. Capital-related payment per diem amounts effective July 1, 2009 are calculated for Peer Group 1, 2 and 3 hospitals based on the Capital-related payment per diem amounts effective during SFY 2007, adjusted for budget neutrality; as follows:

1. Peer Group 1 Capital-Related Payment Per Diem Amounts: Multiply the SFY 2007 Peer Group 1 Capital-related payment per diem amount of $36.00 by the Stable DRG budget neutrality factor.

2. Peer Group 2 Capital-Related Payment Per Diem Amounts: Multiply the SFY 2007 Peer Group 2 Capital-related payment per diem amount of $31.00 by the Stable DRG budget neutrality factor.

3. Peer Group 3 Capital-Related Payment Per Diem Amounts: Multiply the SFY 2007 Peer Group 3 Capital-related payment per diem amount of $18.00 by the Stable DRG budget neutrality factor.

SFY 2007 Capital-Related Cost Payments are described in 471 NAC 10- 010.03B7 in effect on August 25, 2003.

Capital-Related Payment Per Diem Amounts effective July, 2010 will be reduced

by 2.5% effective July 1, 2011. Capital-Related Payment Per Diem Amounts effective July, 2011 will 2 i ic id by 1 ly 1, 2012.

10-010,03B5_Low Volume and Unstable DRG Payments: Discharges that are classified into a Low Volume or Unstable DRG are paid a Low Volume and Unstable DRG CCR payment and, if applicable, a DME payment. Low Volume and Unstable DRG discharges do not receive separate Cost Outlier Payments, IME Cost Payments or Capital-Related Cost Payments.

10-010.03B5a__Low Volume and Unstable DRG: CCR Payments are calculated by multiplying the hospital-specific Low Volume/Unstable DRG CCR by Medicaid allowed claim charges. Low Volume/Unstable DRG CCRs are calculated as follows:

1. Extract from the CMS PPS Inpatient Pricer Program for each hospital the Medicare inpatient prospective payment system operating and capital outlier CCRs effective October 1 of the year preceding the beginning of the Nebraska rate year. For rates effective July 1, 2009, the Department will extract the outlier CCRs in effect for the Medicare system on October 1, 2008.

2. Sum the operating and capital outlier CCRs.

3, Multiply the sum of the operating and capital outlier CCRs by the Low Volume / Unstable DRG budget neutrality factor.

Transmittal # 12-18

Supersedes

PR -3 2013 approves 73 8B Effective JJl ~ 1 2012

Transmittal # 11-22

ATTACHMENT 4.19-A Page 11

On July 1 of each year, the Department will update the Low Volume/Unstable DRG CCRs based on the percentage change in Medicare outlier CCRs effective October 1 of the two previous years, before budget neutrality adjustments.

Effective July 1, 2011, the low volume/unstable DRG CCRs will be reduced by 2.5

percent, Effecti 4, 20 low _volu' le DRG CCRs will be increased by 1. nt. 10-010.03B5b Low Volume and Unstable DRG DME Payments: Low Volume and

Unstable DRG DME payments are calculated using the same methodology described in subsection 10-010.03B3a of this regulation, with the exception that in step 4, per discharge payment amounts are adjusted by the Low Volume/Unstable DRG budget neutrality factor.

On July 1* of each year, the Department will update Low Volume and Unstable DRG DME payment per discharge rates as described in 10-010.03B3a of this regulation.

10-010.03B6 Transplant DRG Payments: Transplant discharges, identified as discharges that are classified to a transplant DRG, are paid a Transplant DRG CCR payment and, if applicable, a DME payment. Transplant DRG discharges do not receive separate Cost Outlier Payments, IME Cost Payments or Capital-Related Cost

Payments. 10-010.0388a Transplant DRG CCR Payments: are calculated by multiplying the

hospital-specific Transplant DRG CCR by Medicaid allowed claim charges. Transplant DRG CCRs are calculated as follows:

4. Extract from the CMS PPS Inpatient Pricer Program for each hospital the Medicare inpatient prospective payment system operating and capital outlier CCRs effective October 1 of the year preceding the beginning of the Nebraska rate year. For rates effective October 1, 2009, the Department will extract the outlier CCRs in effect for the Medicare system on October 1, 2008.

2. Sum the operating and capital outlier CCRs.

3. Multiply the sum of the operating and capital outlier CCRs by the Transplant DRG budget neutrality factor.

On July 1 of each year, the Department will update the Transplant DRG CCRs based on the percentage change in Medicare outlier CCRs effective October 1 of

. the two previous years, before budget neutrality adjustments.

Effective July 1, 2011, the Transplant DRG CCRs will be reduced by 2.5 percent. Effecti uly 1, 2012, the Transplant DRG CCRs_will increas 41,54 percent,

410-010.03B6b Transplant DRG DME Payments: Transplant DRG DME payments are calculated using the same methodology described in subsection 10-010.03B3a of this regulation, with the exception that in step 4, DME per discharge payment amounts are adjusted by the Transplant DRG budget neutrality factor. -

On July 1" of each year, the Department will update Transplant DME payment per discharge rates as described in 10-010.0383a of this regulation.

Transmittal # 42-18 APR -3 2015

Supersedes

Approved Effective joi =} 2012

Transmittal # 11-22

ATTACHMENT 4.19-A Page 17

10-010.03E2 Adjustment of Hospital-Specific Base Payment Amount: The

hospital-specific per diem rates will be increased by .5% for the rate period beginning July 7, 2010. Effective July 1, 2011, the transplant DRG DME rates will be reduced by 2.5%. Effecti ly 1, 2012, the transplant DRG DME rates

will be increased by 1.54%.

10-010.03E3 Calculation of Hospital-Specific Capital Per Diem Rate: Capital- related cost payments for the building and fixtures portion of capital-related costs

are paid on a per diem as described in 471 NAC 10-010.03B7 in effect on August 25, 2003.

10-010.03F Payment for Services Furnished by a Critical Access Hospital (CAH):

Effective for cost reporting periods beginning July 1.2012, and after payment for inpatient services of a CAH is ninety nine percent (99%) of the reasonable cost of providing the services, as determined under applicable Medicare principles of Teimbursement, except that the following principles do not apply: the lesser of costs or charges {LCC) rule, ceilings on hospital operating costs, and the reasonable compensation equivalent (RCE) limits for physician services to providers.

Transmittal # 12-18

Supersedes

APR -3 2013 — Approved ertectived Je ~ 1 2002

Transmittal # 41-22

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION OMB NO, 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF 1. TRANSMITTAL NUMBER: 2. STATE STATE PLAN MATERIAL 12-18 Nebraska

FOR: HEALTH CARE FINANCING ADMINISTRATION

3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID)

TO: REGIONAL ADMINISTRATOR

4, PROPOSED EFFECTIVE DATE

HEALTH CARE FINANCING ADMINISTRATION July 1, 2012 DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One): ([] NEW STATE PLAN (J AMENDMENT TO BE CONSIDERED AS NEW PLAN AMENDMENT

COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment)

6. FEDERAL STATUTE/REGULATION CITATION:

7. FEDERAL BUDGET IMPACT: a. FFY 2012 $433,526 b.FFY 2013 $1,734,104

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

Attachment 4.19-A, Page 5, 6, 8, 10, 11 and 17

9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (ff Applicable):

Attachment 4.19-A, Page 5, 6, 8, 10, 1] and 17

10. SUBJECT OF AMENDMENT; Inpatient Hospital Rate Increase

11, GOVERNOR'S REVIEW (Check One): (2 GOVERNOR'S OFFICE REPORTED NO COMMENT (J COMMENTS OF GOVERNOR’S OFFICE ENCLOSED

[J NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

[x] OTHER, AS SPECIFIED: Governor has waived review

Vivianne M. Chaumont

14, TITLE: Director, Division of Medicaid and Long-Term Care

15. DATE SUBMITTED: gust 20, 2012

16. RETURN TO:

Nancy Keller

Division of Medicaid & Long-Term Care Nebraska Department of Health & Human Services 301 Centennial Mall South

Lincoln, NE 68509

a

FORM HCFA-179 (07-92)

Table of Contents State/Territory Name: NE State Plan Amendment (SPA) #: 13-12 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services 601 East 12th Street, Suite 355 Kansas City, Missouri 64106

Division of Medicaid and Children's Health Operations

March 13, 2014

Vivianne Chaumont, Director Department of Health & Human Services Division of Medicaid and Long Term Care 301 Centennial Mall S., 5th Floor PO Box 95026 Lincoln, Nebraska 68509

Dear Ms. Chaumont:

On December 18, 2013, the Centers for Medicare & Medicaid Services (CMS) received Nebraska’s State Plan Amendment (SPA) transmittal #13-012, which eliminates the requirement of a pretreatment and biopsychosocial assessments from Inpatient Hospital, Early and Periodic Screening and Diagnosis and Treatment (EPSDT), and Rehabilitative services.

SPA 13-012 was approved today, with an effective date of December 1, 2013, as requested by the state. Enclosed is a copy of the CMS-179 summary form, as well as the approved pages for incorporation into the Nebraska State Plan.

If you have any questions regarding this amendment, please contact Sandra Levels or Karen Hatcher at (816) 426-5925.

Sincerely,

//s//

James G. Scott

Associate Regional Administrator

for Medicaid and Children’s Health Operations

Enclosure

cc: Courtney Miller Nancy Keller

Flora Coan

Cynthia Brammeier

Margaret Booth bcc: Sandra Levels

Karen Hatcher

DF.PARTMJ:lNT Of HEALTH AND HUMAN SERVICES HF.ALTH CARE FINANCIN(] ADMINISTRATION TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: HEALTH CARE FINANCING ADMINISTRATION TO: REGIONAL ADM£NTSTRA TOR HEALTH CARE FINANCING ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One): I. TRANSMITTAL NUMBER: 13-12 FORM APPROVED OMA NO. 0938-0193 2. STATE Nebraska 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) 4. PROPOSED EFFECTIVE DATE December 1, 2013 0 NEW STATE PLAN 0 AMENDMENT TO BE CONSIDERED AS NEW PLAN [8:1 AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT Se arate Transmittal {or each amendment) 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: a. FFY 2014 $0.00 b. FFY 2015 $0.00 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION Attachment 3.1-A, Item I, page 2 of2 Attachment 3 .1-A, Item 4b, Page 9 Attachment 3.1-A, Item 13d, page I, 2, 4, 5, 6, and S I 0. SUBJECT OF AMENDMENT: Elimination of Pretreatment and Biopsychosocial Assessment II. GOVERNOR'S REVIEW (Check One): 0 GOVERNOR' S OFFICE REPORTED NO COMMENT 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED 0 NO REPLY RECEIVED WlTHIN 45 DAYS OF SUBMITTAL OR ATTACHMENT (Jf Applicahle): Attachment 3.1-A, Item I, page 2 of2 Attachment 3.1-A, Item 4b, Page 9 Attachment 3.1-A, Item !3d, page I of5, 2 of5, 5, 6 of9, and 8 of9 t8J OTHER. AS SPECIFIED: Governor has waived review 16. RETURN TO: ---------l Nancy Keller Vivianne M. Chaumont Division of Medicaid & Long-Term Care -__:..~:::::::.:..:c::....:..:..:..:......:===---------------l Nebraska Department of Health & Human Services 14. TITLE: 301 Centennial Mall South Director, Division of Medicaid and Lon •-Term Care - ,5-. _D_A_T_E_S-'U'-B- M __;;_;;.;IT;.;.T'-E-D-:-----'-'--'-=-----''---""-----'--"-'-'------- --l Lincoln, NE 68 509 December 18, 20 I3 FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED: 118. DATE APPROVED: PLAN APPROVED - ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL: 20. SIGNATURE OF REGIONAL OFFlCIAL: 21. TYPED NAME: 22. TITLE: 23. REMARKS: FORM HCFA-179 (07-92) December 18, 2013 March 13, 2014 December 1, 2013 James G. Scott Associate Regional Administrator for Medicaid and Children's Health Operations //s//

ATTACHMENT 3.1-A Item 1, Page 2 of 2 Applies to Both Categorically and Medically Needy STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State Nebraska LIMITATIONS -INPATIENT HOSPITAL SERVICES 9. Has the flexibility to meet the schedules of families, guardians and caretakers as necessary; and 10. Documents the attempts to involve family in treatment. Subacute inpatient psychiatric hospital programs must have adequate staff to provide: 1. Comprehensive psychiatric diagnostic evaluations by an attending psychiatrist, nursing assessments, substance abuse assessments as needed, laboratory radiology or other diagnostic tests as necessary. 2. Physical examination and the ability to meet the basic medical needs of the patient. 3. Individual, group, and family psychotherapy by a licensed practitioner. Medication initiation and management services by a psychiatrist. 4. An organized, supervised milieu, psycho-educational services and other support services appropriate. Subacute inpatient psychiatric programs must have adequate staff to meet the needs of the patients served. Essential positions available to the program are: 1. A clinical/program director; 2. Nursing services; 3. Psychotherapy services by a licensed practitioner; 4. Licensed addiction and drug abuse services as needed and appropriate by a licensed individual skilled and trained to treat substance abuse issues; 5. Psycheducational services as necessary; 6. Case Management services. Providers of subacute inpatient hospital services must consider the following conditions to be determine the necessity for treatment. 1. Can the patient benefit from longer term evaluation, stabilization, and treatment services? 2. Is the client moderate to high risk to harm self or others? 3. Does the client have symptoms consistent with a current version of the DSM diagnosis? 4. Does the client have the ability to respond to intensive structured intervention services? 5. Is the client of moderate to high risk to relapse or have symptom reoccurrence? 6. Does the client have a high need of professional structure and intervention services? 7. Can the client be treated with short term intervention services? All subacute inpatient psychiatric services must be prior authorized by the Department or by the Department's contracted designee. Transmittal# NE 13-12 Supersedes Transmittal# NE-08-02 Approved ___ _ Effective ____ _ December 1, 2013 March 13, 2014

ATTACHMENT 3.1~A Item 4b, Page 9 Applies to both Categorically and Medically Needy STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: Nebraska LIMITATIONS- EARLY AND PERIODIC SCREENING AND DIAGNOSIS AND TREATMENT OF CONDITIONS FOUND Services shall be medically necessary and shall be recommended by a psychologist, LIMHP or physician according to an individualized treatment plan, which addresses the eligible individual's assessed needs. An Initial Diagnostic Interview is a comprehensive assessment that identifies the clinical need for treatment and the most effective treatment intervention/level of care to meet the medical necessity needs of the client. The IDI is completed prior to service provision and the IDI documentation accompanies the referral information to the rehabilitation program provider. The recommendations of the licensed supervising practitioner following the Initial Diagnostic Interview serves as the treatment plan until the comprehensive treatment plan is developed. The treatment plan shall specify the frequency, amount and duration of services. The treatment plan shall be signed by the psychologist, licensed mental health practitioner or physician responsible for developing the plan. The plan will specify a timeline for reevaluation of the plan that is at least an annual redetermination. A new treatment plan with a different rehabilitation strategy shall be developed if there is no measure able reduction of disability or restoration of functional level. Agencies and practitioners shall maintain case records that include a copy of the treatment plan, the name of the individual, dates of services provided, nature, content and units of rehabilitation services provided, and progress made toward functional improvement and goals in the treatment plan. Rehabilitation services shall meet the following requirements: • If provided at a work site, the rehabilitation service shall not be job tasks oriented. • Any services or components of services which the basic nature is to supplant housekeeping, homemaking, or basic services for the convenience of a person receiving covered services (including housekeeping, shopping, child care, and laundry services} are not covered. • Services shall not be provided in an Institution for Mental Disease (IMD). • Room and board is excluded from any services or rates provided in a residential setting. • Transportation of children is not included in rehabilitation services or rates. • Education services are not included in or eligible for payment by the Medicaid Program, and do not apply toward the hours of minimum treatment activities for any service in this section. Practitioners shall be familiar with each youth's IEP and coordinate with the youth and the youth's school to achieve the IEP. Education services may not be the primary reason for rehabilitation admission or treatment. Academic education services, when required by law, shall be available. TN No.NE 13-12 Supersedes TN No. 11-10 Approval Date: ___ _ Effective Date ___ _ December 1, 2013 March 13, 2014

ATTACHMENT 3.1-A

Item 13d, Page 1

Applies to both Categorically and Medically Needy

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State Nebraska

LIMITATIONS – REHABILITATIVE SERVICES

Community-Based Comprehensive Psychiatric Rehabilitation and Support Services Program

The following rehabilitative psychiatric services are covered for adult clients who have been diagnosed with severe and persistent major mental illness:

1. Community Support; 2. Day Rehabilitation; and 3. Psychiatric Residential Rehabilitation.

The services must be medically necessary. These services are designed to rehabilitate individuals who are experiencing severe and persistent mental illness in the community and thereby avoid more restrictive levels of care such as psychiatric inpatient hospitalization or nursing facility.

Clients must be assessed by a Nebraska licensed mental health practitioner who can diagnose major mental illness prior to referral, prior authorization and prior to admission to these services. Based on the assessment, the licensed mental health practitioner of the program will supervise the development of a treatment, recovery and rehabilitation plan that identifies rehabilitative and mental health/substance abuse services needed by the client.

Licensed Mental Health Practitioners in the program must meet the requirements of a Nebraska Licensed Mental Health Practitioner as identified by DHHS Division of Public Health, Licensure Unit. Non-licensed staff must prove competency in the treatment of individuals with a mental health diagnosis. Non-licensed staff must meet the requirements for education and experience as defined in each service.

Psychiatric Rehabilitation Agencies must have acquired accreditation by a national accrediting agency such as Joint Commission of Accreditation of Hospitals Organizations (JCAHO), Commission on Accreditation (COA), or Commission on Accreditation of Rehabilitation Facilities (CARF).

The State assures that rehabilitative services are not provided in institutions for mental diseases (IMD).

The State assures that the following programs meet the requirements for rehabilitative services set forth in CFR 440.130(d): Community Support, Day Rehabilitation, and Psychiatric Residential Rehabilitation.

TN No. NE 13-12 Supersedes Approval Date ___________ Effective Date ____________ TN No. 13-23 Revised Submission 2.24.14 December 1, 2013 March 13, 2014

ATTACHMENT 3.1-A Item 13d, Page 2 Applies to both Categorically and Medically Needy STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State Nebraska LIMITATIONS- REHABILITATIVE SERVICES Community Support Community Support is a rehabilitation recovery service delivered by a skilled, trained community support worker under the supervision of a licensed mental health practitioner to individuals suffering from Severe and Persistent Mental Illness (SPMI). The service is delivered through a mental health agency that has achieved and maintained national accreditation by JCAHO, COA, orCARF. Community-Support is designed to: 1. Provide/develop the necessary services and supports to enable clients to reside in the community; 2. Maximize the client's community participation, community and daily living skills, and quality of life; 3. Facilitate communication and coordination between mental health rehabilitation providers that serve the same client; and 4. Decrease the frequency and duration of hospitalization. Community Support Program components: 1. A Treatment Recovery and Rehabilitation Plan developed within 30 days of admission and with updates of the plan every 90 days and reviewed and approved by a licensed mental health practitioner/clinical supervisor. 2. Individualized rehabilitation and recovery services provided by a community support worker according to the plan. 3. Supervision of the community support worker's services delivery by a licensed mental health practitioner. 4. Staff training supervised by the agency's licensed mental health practitioner at the time of initial employment and on an ongoing basis. Community Support services: 1. Assist in coordination of a medical and mental health service. 2. Coordination of all communication with community based supports, including family, education, prevocational and social outlets. 3. Monitor medication adherence and report any barriers. 4. Understand and support use of client's relapse prevention plan. 5. Assist in development of problem solving skills and age appropriate independence TN No. NE 13-12 Supersedes TN No. 09-03 Approval Date ____ _ Effective Date ____ _ December 1, 2013 March 13, 2014

ATTACHMENT 3.1-A Item 13d, Page 4 Applies to both Categorically and Medically Needy STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State Nebraska LIMITATIONS- REHABILITATIVE SERVICES Day Rehabilitation Program components: 1. Review of the diagnostic assessment completed by a community based mental health practitioner who can diagnose major mental illness. The Diagnostic Assessment is the clinical information used to refer the client into the program and is reviewed by the program's licensed mental health practitioner. 2. A licensed mental health practitioner (clinical supervisor) completes a comprehensive assessment within 30 days of admission. 3. The licensed mental health practitioner completes the treatment, recovery and rehabilitation plan in the first 30 days following admission which is reviewed and updated every 90 days. 4. Rehabilitation services are delivered in the therapeutic milieu at least 3 hours to 5 hours of services per day. Service availability includes weekend and evening activity as the client's rehabilitative needs are identified. Day Rehabilitation services: 1. Assist in building daily living skills and time management. 2. Coordinate a prevocational activities to encourage ability for employment 3. Teaching social skills through planned activities. 4. Teaching medication management and it's effectiveness. 5. Assisting in health care access and assist in understanding health care insurance. 6. Skill building in the use of public transportation. 7. Teach money management and financial issues. Direct Care Staff (non:licensed) must have a high school diploma at a m1mmum and have demonstrated skills and competencies in the treatment of individuals with mental health disorders. Direct care staff are directly supervised by individuals licensed as a Licensed Mental Health Practitioner. Residential Rehabilitation Residential Rehabilitation is a 24-hour program that allows a client suffering from severe and persistent mental illness to recover in a rehabilitative setting which includes 20 hours of on-site rehabilitation services and 25 hours off-site services. The agency providing the service must have acquired and maintain national accreditation such as JCAHO, COA, CARF, and be licensed as a Mental Health Center. Room and board are not included in the service. Residential Rehabilitation Program components: 1. A community-based diagnostic assessment by a licensed practitioner who can diagnose major mental illness as a referral into the program. Prior authorization is required for admission. TN No. NE 13-12 Supersedes TN No. 09-03 Approval Date ____ _ Effective Date ___ _ December 1, 2013 March 13, 2014

ATTACHMENT 3.1-A Item 13d, Page 5 Applies to both Categorically and Medically Need STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State Nebraska LIMITATIONS- REHABILITATIVE SERVICES 2. The development of a treatment, recovery and rehabilitation plan developed within 30 days of admission, reviewed and approved by the clinical supervisor who is a licensed mental health practitioner. 3. Service delivery provided by trained direct care staff under the supervision of a licensed clinical supervisor (licensed mental health practitioner). One direct care staff must be available per each 1 0 clients. Specific rehabilitation services are: 1. Assist in arranging medical and psychiatric care and management of appointments. 2. Teaching relapse prevention skills and revisiting the relapse plan with the client. 3. Teaching time management and daily living skills. 4. Social skill development through encouraging healthy relationship building and social activities. 5. Teaching survival skills, such as meal preparation, nutrition, housekeeping activities and other daily management. 6. Money management and budgeting. 7. Prevocational skill development. Psychiatric Residential Rehabilitation is designed to: 1. Increase the client's functioning so that s/he can eventually live successfully in the residential setting of his/her choice, capabilities, and resources; and 2. Decrease the frequency and duration of hospitalization. Non-licensed staff must hold a Bachelor's degree or higher in psychology, sociology, or a related field or two years of coursework in the human services field or two years recovery experience with demonstrated competencies and skills in treatment of individuals with mental health diagnosis. Non licensed staff are supervised by a Nebraska Licensed Mental Health Practitioner who is the Program Supervisor. Secure Psychiatric Residential Rehabilitation Services Secure Psychiatric Residential Rehabilitation Services is a service provided to individuals who have psychiatric symptoms and dysfunctions which cause severe disability. The target population is unable to live outside a high level of 24-hour care. These individuals require a secure setting at times for safety of self and others. TN No. NE 13-12 Supersedes TN No. 09-03 Approval Date ____ _ Effective Date ____ _ December 1, 2013 March 13, 2014