Sec. 10.09.54.20. Conditions for Reimbursement

The Program shall reimburse for the services specified in Regulations .13-.19 of this chapter, if provided in accordance with the requirements of this chapter and if the service:

A. Is recommended on the participant’s plan of service as necessary in order to:

(1) Prevent the applicant’s or participant’s admission to an institution; or

(2) Assure the health and safety of an applicant or participant in the community;

B. Has been pre-approved by the Department in the participant’s plan of service;

C. Is provided to an enrolled participant;

D. Is medically necessary;

E. Is provided by a Medicaid provider who meets the conditions for participation under this chapter; and

F. Is cost-neutral for the Program, which is determined by adding annualized costs of services covered under this chapter and any other State Plan services which are not covered for nursing facility residents, and ensuring that the resulting amount is not more than:

(1) 125 percent of the Program's average per capita-annualized-net payments for nursing facility services for a waiver participant in accordance with the provisions of Regulation .03B(4)(d) of this chapter; and

(2) In the aggregate for all waiver participants, 100 percent of the Program’s average per capita-annualized-net payments for nursing facility services.