Sec. 10.09.10.20. Payment Procedures — Out-of-State Facilities

A. Out-of-State nursing facilities that are not special rehabilitation nursing facilities and do not meet the exception to cost reporting requirements set forth in Regulation .21M of this chapter shall be reimbursed at a rate that is the lesser of:

(1) The average Statewide quarterly rate identified by Regulation .07 of this chapter for in-State nursing facilities minus the quality assessment; and

(2) The out-of-State facility’s Medicaid per diem rate provided by the state in which the facility is located, or, if the state provides the facility with more than one Medicaid per diem rate, the facility’s lowest per diem rate.

B. Out-of-State nursing facilities that are not special rehabilitation nursing facilities and do meet the exception to cost reporting requirements set forth in Regulation .21M of this chapter shall be reimbursed the average Statewide quarterly rate identified by Regulation .07 of this chapter for in-State nursing facilities minus the quality assessment.

C. Out-of-State special rehabilitation nursing facilities shall be reimbursed by the Program when the following conditions are met:

(1) The facility is accredited by the Commission on Accreditation of Rehabilitation Facilities;

(2) The facility is licensed and certified as a nursing facility; and

(3) Services for which reimbursement is requested have been preauthorized by the Program.

D. The rate for each resident in an out-of-State special rehabilitation nursing facility shall be negotiated to:

(1) Be less than the cost of available institutional alternatives; and

(2) Not exceed the home state's Medicaid rate for the same service by the same provider if the provider participates in its home state Medicaid program.