§ 1187.152. Additional reimbursement of nursing facility services related to exceptional DME.
(a) The necessary, reasonable and prudent costs incurred by a nursing facility related to the purchase or rental, and the use of DME in providing nursing facility services to residents are allowable costs and included in the calculation of the case-mix per diem rates subject to this chapter. Any costs incurred in excess of the costs identified in a grant are not allowable costs under this chapter.
(b) When a nursing facility provides nursing facility services involving exceptional DME to an MA eligible resident, the nursing facility may, in addition to the submission of invoices for payment based upon the nursing facility’s case-mix per diem rate, seek authorization for additional payment by requesting a grant from the Department in accordance with § 1187.153(a) (relating to exceptional DME grants—process).
(c) The Department will issue a grant to a nursing facility if the Department determines that all of the following conditions are met:
(1) The nursing facility’s request for the grant complies with all applicable Department instructions.
(2) The specified DME is medically necessary as defined in § 1101.21 (relating to definitions).
(3) The DME specified in the nursing facility’s request is exceptional DME as defined in § 1187.2 (relating to definitions).
(4) The nursing facility’s physical plant, equipment, staff, program and policies are sufficient to insure the safe, appropriate and effective use of the exceptional DME.
(5) The nursing facility certifies to the Department in writing, on a form designated by the Department, that it has read and understands the terms of the grant.
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