Informational Notice

Date:  July 1, 2016                                                           

To:      Long Term Care Facilities - Nursing Facilities (NF)

Re:      Clarification of the Requirements for the Nursing Facility Enhanced Care Rate for Ventilator Services

______________________________________________________________________

This notice provides clarification of requirements for Nursing Facilities (NF) to receive the enhanced care rate for ventilator services. This notice also provides instructions for the completion and submission of form HFS 106, Nursing Facility Ventilator Notification to the Department of Healthcare and Family Services (HFS). Providers are reminded to use the most current version when submitting this form to HFS.

All requirements identified in 89 Ill. Adm. Code 147.335(a) must be met to in order to receive the enhanced care rate. This includes all facility requirements, resident requirements, clinical requirements, staffing requirements and requirements related to the device. Failure to meet any of these requirements may result in the denial of the enhanced care rate for a specific resident or for all the residents on a ventilator in the facility.

In accordance with 89 Ill. Adm. Code 147.335(a), the device must meet the definition of a ventilator, which is defined as any type of electrical or pneumatically powered closed mechanical system for residents who are, or who may become, unable to support their own respiration. It does not include Continuous Position Airway Pressure (CPAP) or Bi-level Positive Airway Pressure (BiPAP) devices. When a ventilator is are used to deliver CPAP or BiPAP it will not be counted as a ventilator service and is not eligible for the enhanced care rate. When a ventilator is set to PEEP or CPAP to aid in the weaning of a resident from a ventilator, the weaning process must be clearly documented in the clinical record in order to receive the enhanced care rate.

In addition, the NF must also correctly code the MDS items and Section S items pertaining to ventilator care and services. Residents for whom a ventilator enhanced care rate is requested will be cross-referenced with the appropriate MDS and Section S items. Failure to correctly code these items may result in denial of the enhanced care rate.

Completion of Form HFS 106 (pdf) (Nursing Facility Ventilator Notification)

The demographic information at the top of form HFS 106 must be completed clearly and accurately. Forms with missing or illegible information will not be processed. The form should include the original admission date and the date of most recent admission. Form HFS 106 should also include the “Medicaid Provider Number” (12 digit number assigned by HFS when a facility is enrolled), which can be found on your Provider Information Sheet; the facility’s “National Provider Identification (NPI)” number; and the “Recipient Identification Number (RIN)” which is a 9 digit number assigned to a resident once determined eligible for Medicaid. The form HFS 106 must be signed, dated and submitted within 5 business days of the requested effective date.

Process for Enrolling a Resident for Enhanced Care Rate for Ventilator Services (Effective Start date for COS 38)

The effective date of Ventilator Services is the date on which “Category of Service 38” (COS 38-Enhanced Care Rate) would apply. This would include the actual admission date (if admitted on a ventilator), the start date of ventilator services (if begun after admission), or the date COS 38 begins after Medicare benefits have been exhausted.

The form HFS 106 (pdf) requesting COS 38 enhanced care rate for ventilator services must include the Physician’s Order Sheet (POS) identifying the need for ventilator services. The POS submitted must correspond to the effective date requested. An evaluation by the licensed Registered Respiratory Therapist (RRT) regarding the ventilator services must also be submitted and must correspond to the effective date requested. Forms submitted without the required POS and RRT evaluation will not be processed. In addition, the hours per day on the ventilator must be documented in the space provided. Additional documentation may be requested by HFS prior to approval of the enhanced care rate, or at any time afterwards, to support continuation of the enhanced care rate.

Process for Dis-enrolling a resident from Enhanced Care Rate for Ventilator Services (Effective Dis-continue Date for COS 38)

A new form HFS 106 (pdf) must be submitted when a resident is dis-enrolled from the ventilator enhanced care rate (COS 38). This would include discharge from the facility (return not anticipated), death, discontinuation of the ventilator services while remaining a resident in the facility, and/or no longer eligible for the enhanced care rate (COS 38). The form HFS 106 must be signed, dated and submitted within 5 business days of the requested discontinue date.

The form HFS 106 should not be submitted to dis-enroll from the enhanced care rate for a hospital admission, as long as the resident has not been discharged (return not anticipated) from the facility. The form HFS 106 must be submitted when the resident is discharged from the facility through the Electronic Data Interchange (EDI) (Medical Data Interchange (MEDI) or Recipient Eligibility Verification (REV)) system.

The effective date for dis-enrolling from the enhanced care rate will reflect the last day the resident received ventilator services in the facility. For example, if a resident goes off the ventilator on January 30, the date entered on the form HFS 106 should be January 30, regardless of the time of day the ventilator was discontinued. If a ventilator-dependent resident is discharged from the facility or dies in the facility, the effective disenrollment date for the enhanced care rate (COS 038) will be the date of discharge or death.

If the resident is taken off the ventilator but remains in the facility, the date ventilator service was discontinued will be the effective disenrollment date for the enhanced care rate (COS 038).

If the resident is actively being weaned from the ventilator, the form HFS 106 requesting disenrollment from the enhanced care rate will be submitted once the weaning is completed. The form HFS 106 should identify the date weaning was initiated and ended. A new POS and a new RRT evaluation identifying the weaning process, the date initiated, and the date ended should be included. The effective disenrollment date for the enhanced care rate (COS 038) will be the date weaning ended.

Submission of form HFS106 (pdf) is also required when the resident is no longer eligible for the enhanced care rate (COS 38) due to starting Medicare coverage (COS 65 and COS 72). The date Medicare coverage started should be identified in the spaces provided.

Notifications

Nursing facilities requesting enhanced care reimbursement will be notified of approvals or denials as soon as the review process is complete.

Effective immediately, form HFS 106 (pdf), the POS and the RRT evaluation must be submitted by secure email to HFS.DMP.BLTC@illinois.gov with the Subject Line “Ventilator Notification”. All communications (including forms and attachments) containing Protected Health Information (PHI) must be emailed to HFS in a secure, HIPAA-compliant format. This email will be monitored by HFS staff on an ongoing basis.

Questions regarding this notice should be submitted to HFS.DMP.BLTC@illinois.gov.

Felicia F. Norwood

Director