The AFH Council receives several calls a week regarding the regulation on Medicaid supplementation. There are narrow, specific times when a provider may request supplementation of a resident’s Medicaid daily rate.
WAC 388-105-0050 (1) defines “supplementation of the Medicaid daily payment rate” as an additional payment requested from a Medicaid recipient or a third-party payer by an adult family home (AFH) provider. This WAC further identifies an AFH provider “may not request supplemental payment of a Medicaid recipient’s daily rate for services or items covered in the daily rate.” In order to determine what a provider may NOT request supplemental payments for, it is important to identify what the Medicaid daily rate includes:
- Activities of daily living. These include dressing, bathing, grooming, locomotion in and out of the resident’s room, eating, bed mobility, body care, and foot care.
- Instrumental activities of daily living. These include meal preparation, housework, essential shopping, laundry, coordinating medical services, managing finances, telephone use, and medication management.
- Recreational activities such as cards, puzzles, etc., meals/refreshments, furnishings, and the use of linens/towels.
So, an AFH provider may not request additional payments from the resident or third party payer for the provision of activities of daily living (ADLs) or instrumental activities of daily living (IADLs), regardless of the resident’s assessed level of reimbursement in the CARE assessment.
According to WAC 388-105-0050, AFH providers may, however, request supplemental payments for items and services not included in the Medicaid contract. For example, hair salon services, massage services, manicures, pet care, concerts or other costly activities are all outside the auspices of the Medicaid contract. Per RCW 70.129.030 the provider must, prior to admission and at least every 24 months, review the charges for these services via the home’s admission agreement. Changes to these charges require a 30-day advanced written notice.
Perhaps the most common supplemental payment request by AFH providers is for the provision of a private room. Many Medicaid-funded residents share a bedroom with another resident, effectively reserving the private bedrooms for residents who pay a higher private-pay monthly amount. WAC 388-105-0050 and -0055 allow the AFH provider to request a supplemental payment for those Medicaid-funded residents who wish to live in a private bedroom, perhaps with a private bath or some other amenity not enjoyed by those residents who share a bedroom.
For those AFH providers who wish to request a supplemental payment for the provision of a private bedroom for Medicaid residents, WAC 388-105-0050 outlines what the home’s policy must address, and includes:
- Which bedrooms will require supplementation;
- Action the contractor will take when a private pay resident converts to Medicaid and the resident or a third party is unwilling or unable to pay a supplemental payment in order for the resident to remain in his/her unit or bedroom;
- When the only units or bedrooms available are those for which the contractor charges a supplemental payment, the contractor’s policy may require the Medicaid resident to move from the home. However, the contractor must give the Medicaid resident thirty days notice before requiring the Medicaid resident to move.
This policy must be given to all current and prospective residents.
Whenever the AFH receives supplemental payments for a private room, the provider must include in the Medicaid resident’s file:
- Unit or bedroom for which the contractor is receiving a supplemental payment;
- Services, items, or activities for which the contractor is receiving supplemental payments;
- Who is making the supplemental payments;
- Amount of the supplemental payments; and
- Private pay charge for the unit or bedroom for which the contractor is receiving a supplemental payment.
In addition, the provider must notify the resident’s case manager of the supplemental payment.
The most common mistake made by AFH providers in requesting supplementation is the idea that these additional funds are collected to “bridge the gap” between what Medicaid reimburses the provider to care for the resident, and what the provider would charge if the resident were paying privately. To do this would be considered Medicaid fraud, and would likely be investigated by the DSHS Medicaid Fraud unit.
The purpose for the supplemental payment, then, is to reimburse the provider for the difference Medicaid expects the resident to pay for the room and what the AFH provider would charge the private-paying resident for the same room. This charge does not include the charges associated with caring for the resident; it only reflects the charge for the physical space – the private bedroom. So, for example, if DSHS expects the Medicaid resident to pay $600 towards the cost of the room, and the provider would charge a privately-paying resident $1,400 for the cost of the room, the provider may request a supplemental payment of $800 from the Medicaid resident or third party payer.
Members of the AFH Council can find a sample Medicaid Supplementation Policy in the document library under “I’m Licensed-Now What?” then “Admitting a Resident”. Please reach out to our Education & Support team if you have any questions.
One Response
Is it ok to charge for a shared rrom. I am thinking not and hope this is made clear to providers. also, charging for night care when night care is not needed by the resident, but they are charging all clients and sharing the cost of that care. Thanks, Bonnie
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