Nursing Facility Leave Days
Change in Medicaid member benefit for nursing facility leave
days
As announced in bulletin BT201061, the Indiana
Health Coverage Programs (IHCP) will no longer cover "bed-hold"
days in a nursing facility (NF) as a member benefit effective
February 1, 2011.
This change has an impact on all IHCP members. All IHCP members
residing in a nursing facility have been notified of this change in
their benefit and have been directed to talk with the individual
provider regarding any type of "bed-hold" or leave day policy that
may exist in that facility.
We have received many questions regarding this change and would
like to provide the following guidance.
Frequently Asked Questions
Is there a requirement that nursing facilities hold beds?
No, there is no requirement that nursing facilities hold
beds.
What policies must facilities have in place regarding bed
holds?
The facility must inform a resident in writing prior to a
hospital transfer or departure for therapeutic leave that Medicaid
does not pay for bed holds and what the nursing facilities'
policies are regarding bed-hold periods. A nursing facility is
required to establish and follow a written policy under which a
resident whose hospital or therapeutic leave exceeds Medicaid
coverage limitations is re-admitted to the facility upon the first
availability of a bed in a semiprivate room, if the resident
requires NF level services and is eligible for Medicaid NF
services. See 42 CFR 483.12(b)(3) and 410 IAC
16.2-3.1-12(a)(27) (see below). This means that
regardless of the length of leave, if the individual remains
eligible for nursing facility level of care and Medicaid, he or she
must be re-admitted to the facility to the first available
bed.
410 IAC 16.2-3.1-12 Transfer and discharge rights
Sec. 12. (a) The transfer and discharge rights of residents
of a facility are as follows:
(25) Before a facility transfers a resident to a hospital or
allows a resident to go on therapeutic leave of twenty-four (24)
hours duration or longer, the facility must provide written
information to the resident and a family member or legal
representative that specifies the following:
(A) The duration of the bed-hold policy under the Medicaid
state plan during which the resident is permitted to return and
resume residence in the facility.
(B) The facility's policies regarding bed-hold periods,
which must be consistent with subdivision (27), permitting a
resident to return.
(26) Except in an emergency, at the time of transfer of a
resident for hospitalization or therapeutic leave, a facility must
provide to the resident and a family member or legal representative
written notice which specifies the duration of the bed-hold policy
described in subdivision (25).
(27) Medicaid certified facilities must establish and follow
a written policy under which a resident, whose hospitalization or
therapeutic leave exceeds the bed-hold period under the state plan,
is readmitted to the facility immediately upon the first
availability of a bed in a semiprivate room if the
resident:
(A) requires the services provided by the facility; and (B)
is eligible for Medicaid nursing facility services.
Because Medicaid will no longer pay to hold beds in nursing
facilities under any circumstances, all bed holds for days of
absence are considered noncovered services for which the resident
may elect to pay. If the facility offers this option, the facility
must include this information in its written policy, as well as the
written information provided to the resident prior to hospital
transfer or departure for therapeutic leave. The information must
at least include the following: that Medicaid does not pay for bed
holds; the resident's option to pay to hold a bed (if the facility
offers that option); and the amount of the facility's charge.
Facilities cannot establish a minimum bed-hold charge, such as a
certain number of days, because this could overlap with covered
services if the resident returns before the minimum period lapses.
The facility must also follow the requirements for billing
recipients for noncovered services set forth in the Indiana
Health Coverage Programs Provider Manual, Chapter 4, Section
5. Further, it is the resident's choice to elect to pay for
this service. Facilities can charge residents only for items and
services requested by the resident. See 42 CFR
483.10(c)(8).
Nursing facilities are also obligated to inform residents upon
admission of services for which the resident may be charged and the
amounts of those charges. Residents must also be informed of any
changes to available services and any charges. See 42 CFR
483.10(b)(5) - (6). Facilities must provide 30 days' advance
written notice to residents of any changes in rates or services
that the rates cover. See 410 IAC 16.2-3.1-4(i).
Why must a facility allow a Medicaid recipient to be
re-admitted to the facility to the first available bed?
410 IAC 16.2-3.1-12 (Transfer and Discharge Rights) states:
"Medicaid certified facilities must establish and follow a written
policy under which a resident, whose hospitalization or therapeutic
leave exceeds the bed-hold period under the state plan, is
re-admitted to the facility immediately upon the first availability
of a bed in a semi-private room if the resident: a) requires the
services provided by the facility; and b) is eligible for Medicaid
nursing facility services." As of February 1, 2011, Indiana does
not recognize a "bed-hold period" under the state plan. The absence
of a bed-hold period in the state plan, however, does not negate
the facility's responsibility to re-admit the Medicaid recipient to
the facility at the first availability of a bed in a semiprivate
room if:
- The resident requires the services
- The resident is eligible for Medicaid nursing facility
services, AND
- The facility can meet the needs of the specific resident being
re-admitted.
When are facilities required to resubmit pre-admission
screening forms and a new form 450B following a hospital or
therapeutic leave of absence? When are they not required to submit
these forms?
The nursing facility is not required to submit
a new form 450B or to process a new Indiana Pre-Admission Screening
(PAS) application for re-admission following a hospitalization or
therapeutic leave if the resident has not been discharged. As long
as the resident intends to return to a nursing facility, there is
no requirement to discharge the resident.
To clarify, if the resident intends to return to the sending
nursing facility or to transfer to another nursing facility, a new
Indiana Pre-Admission Screening application is not required. If a
resident does not return to the sending facility, however, but
chooses to transfer to another facility following hospitalization,
the new facility must complete a new form 450B and notify the local
Area Agency on Aging of the resident's admission to the new
facility. The pre-admission screening application and paperwork
from the prior facility can be requested by and forwarded to the
new facility.
The key factor in determining if a resident must go through the
pre-admission screening process is whether the resident goes home.
As long as the resident does not discharge from the hospital to
home, it will not be necessary to complete the entire pre-admission
screening process - only a new form 450B is required if the patient
transfers to a new nursing facility. If the resident does discharge
from the hospital to home, the resident will have to undergo the
full pre-admission screening process - including the pre-admission
screening application and the form 450B - to be re-admitted to any
long term care facility.
If the nursing facility does not anticipate the return of the
resident, the resident must be discharged from the nursing
facility, and all applicable new admission criteria (for example,
PAS, 450B) must be followed if the resident is re-admitted to the
nursing facility.
How does a facility decide when a resident should be
discharged?
This decision is at the discretion of the facility. There is no
"benefit," however, to discharging a resident prematurely, prior to
knowing the resident's intent following the end of a hospital stay.
The facility must re-admit a Medicaid recipient if the recipient is
eligible, and his or her needs can be met. If the resident is
re-admitted to the same facility (even after 30 days or more of
hospitalization), pre-admission screening need not be repeated, as
long as the resident did not return to home prior to re-admission
to the facility.
How should facilities account for bed-hold days in the case mix
system?
Because bed hold days will no longer be eligible for IHCP
payment, there is no longer any need to report them on the Nursing
Facility Financial Report, effective for dates of service on and
after February 1, 2011.
Under what circumstances, if any, should the nursing facility
submit a claim for bed-hold days?
Under the policy in effect through January 31, 2011, nursing
facilities are required to submit claims for bed-hold days
regardless of whether those leave days are eligible for payment.
Beginning February 1, 2011, it will no longer be necessary to
submit claims for bed-hold days under any circumstances, even for
Revenue Code 180 (bed-hold days not eligible for payment). This is
because the State will no longer track bed-hold days.
Addtional Information
If you have additional questions, please contact your HP Provider Relations
field consultant directly or HP Customer Assistance at (317)
655-3240 in the Indianapolis local area or toll-free at
1-800-577-1278.