Section 75-02-06-22 - Participation requirementA facility must comply with the following provisions in order to be eligible to receive medical assistance payments.
1. A facility may not charge private-pay residents rates that exceed those rates approved by the department for medical assistance recipients, except that: a. A facility may charge a higher rate for a private room. b. A facility may charge for special services not included in the daily rate if medical assistance residents are charged separately at the same rate for the same services. Special services must be available to all residents and residents must be free to select or decline the special services. Special services may not include services provided by the facility in order to comply with licensure or certification standards which, if not provided, would result in a deficiency or violation by the facility. Services beyond those required to comply with licensure or certification standards may not be charged separately as special services if the services were included as allowable costs used to establish the current established rate. Special services may include cable television, telephones, long-distance calls, nonroutine hair care such as permanents requested by a resident, and the additional cost of brand name supplies requested by a resident and not ordinarily stocked. A facility shall inform the resident or a person acting on behalf of the resident that a charge may be made and the amount of the charge at the time a request for the special services is made. c. A facility may charge to hold a bed for a period in excess of the periods covered by subsections 3, 4, 5, and 6 of section 75-02-06-14 if: (1) The resident, or a person acting on behalf of the resident, has requested the bed be held and the facility informs the person making the request, at the time of the request, of the amount of the charge; (2) For a medical assistance resident, the payment comes from sources other than from the resident's monthly income; and (3) All residents are charged the same amount. d. A facility may charge for medicare part A and part B coinsurance and deductibles. 2. A facility may not require, as a condition of admission, any applicant to pay a fee or a deposit, loan any money to the facility, or promise to leave all or part of the applicant's estate to the facility. 3. A facility may not require any resident to use a vendor of health care services who is a licensed physician or pharmacist chosen by the facility. 4. A facility may not provide differential treatment on the basis of status with regard to public assistance. 5. A facility may not discriminate in admission, services offered, or room assignment on the basis of status with regard to medical assistance. The collection and use by a facility of financial information of any applicant pursuant to a preadmission screening program does not raise an inference that the facility is using that information for any purpose prohibited by this chapter. Admission discrimination includes: a. Basing admission decisions upon an assurance by the applicant to the facility, or the applicant's guardian or conservator, that the applicant is neither eligible for nor will seek medical assistance for payment of facility care costs; or b. Engaging in preferential selection from waiting lists based on an applicant's ability to pay privately. 6. A facility may not require any vendor of medical care, who is reimbursed by medical assistance under a separate fee schedule, to pay any portion of the fee to the facility except as payment for the fair market value of renting or leasing space or equipment of the facility or purchasing support services, if those agreements are disclosed to the department. 7. A facility may not refuse, for more than twenty-four hours, to accept a resident returning to the same bed or an available bed certified for the same level of care, in accordance with a physician's order authorizing transfer, after receiving inpatient hospital services. 8. A facility may not violate any rights of a health care facility resident as set forth in North Dakota Century Code section 50-10.2-02. 9. Any facility certified as a nursing facility shall participate in medicare part A and part B with respect to at least thirty percent of the beds in the facility. 10. If medicare covered services are provided to a resident who is simultaneously eligible for medical assistance and medicare, the facility shall bill for medicare part A and part B before billing medical assistance, and may not bill medical assistance if the resident, or someone acting on the resident's behalf, has refused or waived use of available medicare benefits. The department may be billed only for charges not payable by medicare. Medicare part B covered services are not included in the daily rate. 11. A facility shall file on behalf of each resident or assist each resident in filing requests for any third-party benefits to which the resident may be entitled. 12. A facility shall be certified to participate in the medical assistance program and have a provider agreement with the department. 13. If a facility does not comply with the provisions of this section, the department may continue, if extreme hardship to the residents would otherwise result, to make medical assistance payments to the facility for a period not to exceed one hundred eighty days from the date of mailing a formal notice. In these cases, the department shall issue an order requiring the facility to correct the violation. If the violation is not corrected within the twenty-day period, the department may reduce the payment rate to the facility by up to twenty percent. The amount of the payment rate reduction must be related to the severity of the violation and must remain in effect until the violation is corrected. The facility may seek reconsideration of or appeal the department's action as provided for in section 75-02-06-25. 14. A facility may charge a higher rate for a private room used by a medical assistance resident if: a. The private room is not medically necessary; b. The resident, or a person acting on behalf of the resident, has requested the private room and the facility informs the person making the request, at the time of the request, of the amount of the payment and that the payment must come from sources other than a resident's monthly income; and c. The payment does not exceed the amount charged to private-pay residents. 15. A facility may not accept any payment to hold a bed prior to the admission of a resident. 16. A facility shall readmit a resident whose leave exceeds the facility's bed hold period upon the first availability of a bed in a semiprivate room if the resident: a. Requires the services provided by the facility; and b. Is eligible for medical assistance. 17. A facility may not charge a managed care organization a rate that is less than the rate approved by the department for a medical assistance recipient in the same classification. N.D. Admin Code 75-02-06-22
Effective January 1,1996; amended effective January 1, 1998; January 1, 2000.General Authority: NDCC 50-24.1-04, 50-24.4-02
Law Implemented: NDCC 50-24.4; 42 USC 1396 a(a)(13)