Adult Medicaid Manual MA-2905- MEDICAID COVERED SERVICES

VIi. NURSING FACILITY SERVICES

Refer to DMA’s website at http://www.dhhs.state.nc.us/dma/mp/mpindex.htm for specific coverage criteria, prior approval requirements, and service limitations.

A. Covered Services

While not all inclusive, items stated below are covered in the per diem for each facility:

1. Room and board, including therapeutic diets with feeding assistance and general nursing services as needed.

NOTE: The Medicaid per diem rate is for semiprivate room, unless the recipient’s attending physician orders a private room or a private room is the only available room.

2. Therapeutic leave.

3. Non-prescription drugs, such as aspirin, antacids, etc.

4. Biological serums and vaccines, such as flu vaccines and TB skin test.

5. Physical therapy, speech and language pathology, and occupational therapy.

6. Diagnostic services, including laboratory, radiology, and other required diagnostic services.

7. Medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well being of the resident.

8. Activity services to meet the interests and physical, mental, and psychosocial well being of the resident.

9. Personal laundry (no dry cleaning).

10. Supplies and equipment

a. Medical supplies such as IV solutions and tubing, tracheostomy supplies, catheters, colostomy bags and supplies

b. Dressings, adhesive tapes, antiseptic solutions, and skin care items used in the treatment of wounds, decubitus ulcers, skin tears, etc.

REVISED 08/01/11 – CHANGE NO. 16-11

(VII. A. 10)

c. Personal hygiene items such as soap, shampoo and conditioner, toothbrush and toothpaste, lotion, tissues, razors, deodorant, denture adhesive, incontinency pads and pants, etc.

d. Items furnished to all patients on a routine basis such as gowns, water pitchers, bedpans, linens, etc.

e. Medical equipment such as canes, crutches, walkers, wheelchairs, etc.

f. Special dietary supplements used for tube feeding or oral feeding, such as elemental high nitrogen diet (these supplements have been classified by the FDA as a food not a drug)

g. Other miscellaneous items such as tube feeding equipment/solutions, restraints, etc.

11. Transportation is directly paid to the nursing facility. DMA directly reimburses long term care facilities for non-ambulance transportation of Medicaid eligible patients to receive medical care that cannot be provided in the facility. This reimbursement is included in the total cost of care paid to the facility.

See MA-2910, Medicaid Transportation, for detailed coverage and procedures.

B. Non Covered Services

1. Private rooms, EXCEPT if ordered by a physician for medical necessity or if another room is not available

2. Reservation of bed during an absence, e.g. hospitalization

3. Patient monthly liability as determined by county Department of Social Services

4. Personal items, such as telephones, televisions, clothing, cosmetics, tobacco products, etc.

5. Non-routine hair care such as set, hair color, permanent wave

6. Guest trays

7. Morgue boxes, shrouds, or burial wrappings

8. Some transportation (See MA-2910, Medicaid Transportation, for detailed coverage and procedures)

REVISED 08/01/11 – CHANGE NO. 16-11

(VII. B.)

9. Private duty nurses, unlicensed personnel, sitters/attendants/companions

10. Medical photography

NOTE: Relative to numbers 9 and 10 above for recipients under the age of 21 in regard to EPSDT requirements, see I. and XXXVIII. of this manual section.

C. Restrictions

Physician visits made to a recipient in a nursing facility are not counted toward a recipient’s professional services visit limit.

D. Copayments

Medicaid recipients who are residents of a nursing facility are exempt from copayments.

E. Prior Approval

It is the provider's responsibility to obtain prior approval if needed. (Refer to II.G. for additional information.)