5010 REIMBURSEMENT

5010.1 Each Provider shall be reimbursed sixteen dollars and thirty cents ($ 16.30) per hour for services rendered by a personal care aide.

5010.2 Reimbursement for PCA services shall not exceed eight (8) hours of service per day per beneficiary. Reimbursement for services shall not exceed one thousand forty (1,040) hours during a calendar year, unless previously approved by DHCF or its agent

5010.3 Each Provider shall agree to accept as payment in full the amount determined by DHCF as Medicaid reimbursement for the authorized services provided to beneficiaries. Providers shall not bill the beneficiary or any member of the beneficiary's family for PCA services.

5010.4 Each Provider shall agree to bill any and all known third-party payers prior to billing Medicaid.

5010.5 All reimbursable claims for PCA services shall include the NPI numbers for the:

(a) Provider;

(b) Primary care physician or advanced practice registered nurse who ordered the personal care services;

(c) Staffing agency providing the personal care service, if the staff performing personal care services were obtained from a staffing agency; and

(d) Personal care aide who provided the personal care services.

5010.6 No more than ten percent (10%) of the billed units of service for PCA services, billed by date of service, in any given four (4) month period, may be claimed by a Provider for PCA services provided through the use of personnel from a staffing agency or agencies.

5010.7 Medicaid shall deny, pursuant to 42 C.F.R. § 424.22(d), home health services claims or recoup paid claims when Provider records or other evidence indicate that the primary care physician or advanced practice registered nurse ordering a beneficiary's treatment has a significant ownership interest in, as defined in § 5010.8, or a significant financial

or contractual relationship with, as defined in § 5010.9, the home health agency billing for the services.

5010.8 A primary care physician or advanced practice registered nurse shall be considered to have a significant ownership interest in a home health agency if either of the following conditions apply:- (a) The primary care physician or advanced practice registered nurse has a direct or indirect ownership of five percent (5%) or more in the capital, stock, or profits of the home health agency; or

- (b) The primary care physician or advanced practice registered nurse has an ownership of five percent (5%) or more of any mortgage, deed of trust, or other obligation that is secured by the agency, if that interest equals five percent (5%) or more of the agency's assets.5010.9 A primary care physician or advanced practice registered nurse is considered to have a significant financial or contractual relationship with a home health agency if any of the following conditions apply:- (a) The primary care physician or advanced practice registered nurse receives any compensation as an officer or director of the home health agency;

- (b) The primary care physician or advanced practice registered nurse has indirect business transactions, such as contracts, agreements, purchase orders, or leases to obtain services, supplies, equipment, space, and salaried employment with the home health agency; or

- (c) The primary care physician or advanced practice registered nurse has direct or indirect business transactions with the home health agency that, in any fiscal year, amount to more than twenty-five thousand dollars (\$25,000) or five percent (5%) of the agency's total operating expenses, whichever is less.5010.10 Claims resulting from staffing agency referrals, marketing (such as, face-to-face solicitation at doctors' offices, home visits), requests for beneficiary Medicaid numbers, or otherwise directing beneficiaries to any Medicaid Provider shall not be reimbursed.

SOURCE: Final Rulemaking published at 50 DCR 3957(May 23, 2003); as amended by Notice of Final Rulemaking published at 59 DCR 1760, 1776 (March 2, 2012).