Clarification: Nursing Facility Leave Days

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.