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Minnesota Department of Human Services Provider Manual
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Nursing Facilities

Revised: 06-23-2014

  • Definitions
  • Eligible Providers
  • Eligible Recipients
  • Physician Certification
  • Physician Visits for NF and Boarding Care Recipients
  • Discharge and Transfer
  • Penalty for Late or Non-Submission of Resident Assessment
  • Nursing Assistant (NA) Registry
  • Information in Registry
  • Contacting the Registry
  • Information on Nurse Aide Reimbursement
  • Preadmission Screening (PAS) Under State and Federal Statutes
  • Preadmission Screening for Mental Illness or Developmental Disability
  • Preadmission Screening for NF Level of Care Determination
  • Individuals Under 21 Years of Age
  • Preadmission Screening and Medical Assistance Reimbursement
  • Emergency Admissions
  • County Responsibility
  • Nursing Facility and Boarding Care Home Responsibility
  • Covered Services
  • Additional Charges for Special Services
  • Rehabilitative Services
  • Leave Days (SNF/NF/BCH)
  • Determining the Number of Leave Days
  • Occupancy Rate
  • Eligible Provider
  • Eligible Recipients
  • Preadmission Screening
  • Limitations
  • Ancillary Services
  • Billing Guidelines
  • Exceptions
  • Conditions of Participation
  • Solicitation of Contributions
  • Administration of Resident Fund Accounts
  • Limitations on Use of Trust Funds
  • Definitions
  • Legal References
  • Eligible Providers

    Skilled nursing facilities (SNF), nursing facilities (NF), or boarding care homes (BCH), licensed as Nursing Facility providers by the Minnesota Department of Health (MDH. Swing bed hospital provider eligibility information is specified in the Swing Bed section of this section.

    Facilities with distinct part certification must admit and care only for those MA recipients certified as requiring the same level of care as the bed certification.

    Exemption: An SNF or ICF that is operated, listed, and certified as a Christian Science sanatorium by the First Church of Christ Scientist, of Boston, Massachusetts, is not subject to the federal regulations for utilization control in order to receive MA payments for the cost of recipient care.

    Eligible Recipients

    Nursing Facilities provide services to individuals who have been screened and determined to need a nursing facility level care.

    MA eligible recipients must reside in a certified bed that matches his or her certified level of care.

    MA will cover the cost of care for a recipient who resides in a certified NF or certified BCH, if the following requirements are met:

    Certified Nursing and Certified Boarding Care Facility

  • • The care is ordered by a physician
  • • The nursing facility is in compliance with state and federal regulations
  • • The care provided in an NF or BCH is required as determined through the preadmission screening process completed by the county prior to admission to the facility.
  • Swing Bed Hospital

    Specifications are in the Swing Bed section.

    Physician Certification

    A physician must certify the need for a certified NF or certified boarding care facility. A Physician Certification (DHS-1503) form must be completed in the following instances:

  • • Upon initial admission or upon readmission following discharge
  • • When a recipient transfers from one nursing facility to another
  • • When a recipient transfers within the facility from one level of care to another
  • • When a recipient returns from an unauthorized leave exceeding 24 hours
  • • When a recipient returns from hospitalization, if their level of care changes
  • Telephone orders cannot be used for physician certification purposes. Written orders signed and dated by a physician are permissible for this purpose, or a physician may sign and date the Physician Certification (DHS-1503) form.

    The Physician Certification form must be completed by the:

  • Facility: Within 30 days prior to the admission date, or on the date of admission. Payment will begin on the date the physician signs and dates orders for admission or the Physician Certification form or the actual admission date, whichever is later
  • Physician Visits for NF and Boarding Care Recipients

    Under state rule, a certified NF or boarding care resident must be examined by a physician within five days prior to or 72 days after admission. After the admitting examination, the resident must be seen at least every 30 days for the first 90 days after admission and at least every 60 days thereafter.

    When a recipient on a 60-day schedule of visits is transferred to a hospital and returns to the same NF, it is not necessary to begin a new 30-day schedule of visits for 90 days. The next required routine physician visit would occur 60 days after the recipient returns from the hospital.

    At the discretion of the physician and in accordance with facility policy, required visits after the initial visit may alternate between personal visits by the physician and visits by a physician assistant, certified nurse practitioner, or clinical nurse specialist. The physician assistant, certified nurse practitioner or clinical nurse specialist must not be an employee of the NF. Refer to Physician and Professional Services for supervision requirements for physician extenders.

    Residents who would otherwise be on a 60-day visit schedule, but refuse to see their physician this often, may waive this requirement. Under state law, physicians must see nursing home residents at least every six months and boarding care home residents at least once per year. Each refusal must be documented in the recipient’s medical record and signed by the resident and the physician.

    Discharge and Transfer

    When a resident is discharged, he/she is terminated from a residential treatment period of care through the formal release or death of the resident. The record must contain a discharge summary signed by a physician and the facility must notify the county. Payment is not made for reserving a bed after discharge. If the resident returns to the facility, all admission record requirements must be completed.

    When a resident is transferred, he/she is temporarily placed into an inpatient hospital (not including regional treatment centers or other nursing facilities) and the facility holds the bed for the resident. The medical record must indicate the resident was absent from the facility and upon return must be updated with any changes. A transfer does not prohibit a facility from thinning the medical record.

    In addition, any transfer, discharge or relocation of residents must comply with all applicable federal or state laws, including the state Resident Relocation law, found in M.S. 144A.161.

    Resident Classification System
    The case mix system utilized for Minnesota nursing facilities (NFs) certified for Medicaid (MA or Medical Assistance) is based on the federally required minimum data set (MDS), version 3.0. The RUGS-III, 34 group model was modified to 36 groupings and used to establish Minnesota case mix classifications. These case mix classifications, in part, determine the per diem (daily) rates for residents residing in Minnesota nursing facilities.

    The following resident assessments must be conducted by the facility in accordance with the most current CMS guidelines, and are used in determining a resident’s case mix classification for reimbursement purposes:

  • • Admission assessment
  • • Annual assessment
  • • Significant change assessment
  • • Quarterly assessments
  • • Significant correction to prior Comprehensive Assessment
  • • Significant correction to prior Quarterly Assessment
  • Nursing facilities conduct the MDS assessment on each resident and transmit that data to the Minnesota Department of Health (MDH). The MDH then determines the resident’s case mix classification based on the MDS data and notifies the facility, who in turn notifies the resident. MDH also transmits this data to the Department of Human Services (DHS), for use in determining the facility’s reimbursement (per diem) rates. MDH also conducts regular audits of the MDS data submitted by NFs to ensure the data is accurate. Audits conducted by the MDH may result in changes to the resident’s case mix classification and therefore their per diem rate. The nursing facility or the resident may request a reconsideration of the case mix classification from MDH. Case-mix related functions are conducted by the MDH on behalf of the Medicaid program under contract to the DHS (the Medicaid Agency).

    For more information on Minnesota case-mix for nursing facilities, follow this link to the MDH website:

    http://www.health.state.mn.us/divs/fpc/profinfo/cms/

    Penalty for Late or Non-Submission of Resident Assessment

    A facility that fails to complete or submit an assessment for a case-mix classification within seven days of the time required is subject to a reduced rate for that resident. The reduced rate will be the lowest rate for that facility. The reduced rate is effective on the day of admission for new admission assessments, or on the day that the assessment was due, for all other assessments. The reduced rate continues in effect until the first day of the month following the date of submission of the resident’s assessment.

    Nursing Assistant (NA) Registry

    Nursing Assistant Training and Competency Evaluation

    A nursing facility may employ an individual working in the facility as a nursing assistant for more than four months, if the individual:

  • • Is a permanent employee, competent to provide nursing and nursing related services
  • • Has successfully completed an approved training and competency evaluation program or a competency evaluation program approved by the state
  • • Has been deemed or determined competent as provided by the MDH
  • A nursing facility may employ an individual working in the facility as a nursing assistant for less than four months, if the individual meets one of the following criteria:

  • • Is a permanent employee enrolled in an approved training and competency evaluation program
  • • Has demonstrated competence through satisfactory participation in a state approved training and competency evaluation program or competency evaluation
  • • Has been deemed or determined competent as provided by the MDH
  • A nursing facility may employ a non-permanent (temporary or contract) employee working in the facility as a nursing assistant, if the individual:

  • • Is competent to provide nursing and nursing-related services
  • • Has successfully completed a training and competency evaluation program or a competency evaluation program approved by the state
  • Nursing facilities may employ an individual to work as a nursing assistant if the individual meets any of the requirements outlined above, but the facility must also seek and obtain a copy of the Nursing Assistant Registry verification for the permanent employment file. In the case of non-permanent (temporary or contract) staff, the nursing facility remains the responsible party to ensure that staff employed in their facility meet all requirements.

    Information in Registry

    The Nursing Assistant Registry includes substantiated findings of resident abuse, neglect, or misappropriation of resident property involving an individual listed in the Registry. It may also include a brief statement by the individual disputing the findings.

    Contacting the Registry

    When the Nursing Assistant Registry is contacted by telephone, the nursing facility will receive immediate verbal verification of the individual’s status on the Registry. If the NA is active on the registry, the facility can request an inquiry letter be mailed or faxed verifying the Nursing Assistant’s status. The facility will be instructed to speak to a registry representative if the NA is inactive, not on the registry, or has abuse allegations or findings on record.

    Contact the Registry at:

    Minnesota Department of Health
    Nursing Assistant Registry
    85 East 7th Place, Suite 300
    P.O. Box 64501
    St. Paul, MN 55164-0501
    651-215-8705 or 1-800-397-6124
    health.FPC-NAR@state.mn.us

    Information on Nurse Aide Reimbursement

    For questions related to nurse aide reimbursement policies, contact:

    Long-Term Care Policy Center
    651-431-2282
    DHS.LTCpolicycenter@state.mn.us

    Preadmission Screening (PAS) Under State and Federal Statutes

    Minnesota statutes and federal law require that all applicants to certified nursing facilities, hospital "swing" beds, and certified boarding care facilities be screened by the county prior to admission.

    The purpose of the preadmission screening program is to prevent or delay certified nursing facility placements by assessing applicants and residents and offering cost-effective alternatives appropriate for the person’s needs. Another goal of the program is to contain costs associated with unnecessary certified nursing facility admissions. The purpose of the screening activity is to determine the need for nursing facility level of care, and to complete activities required under federal law related to mental illness and developmental disability.

    Preadmission Screening for Mental Illness or Developmental Disability

    All applicants to certified nursing and boarding care facilities, as well as hospital "swing" beds must be screened prior to admission, regardless of income, assets, or funding sources, and except as outlined below. A person who has a diagnosis or possible diagnosis of mental illness or developmental disability must receive a preadmission screening before admission, regardless of the exemptions related to level of care determinations outlined below, to identify the need for further evaluation and/or specialized services, unless the admission prior to screening is authorized by the local mental health authority or the local developmental disabilities case manager, or unless authorized by the county agency according to Public Law Number 100-508.

    The local agency will use qualified professionals, and forms and criteria developed by the commissioner to identify people who require referral for further evaluation and determination of the need for specialized services.

    The local county mental health authority or the state developmental disability authority under Public Law Numbers 100-203 and 101-508 may prohibit admission to a nursing facility if the individual does not meet the nursing facility level of care criteria or needs specialized services as defined in Public Law Numbers 100-203 and 101-508.

    Exemptions: Exemptions from the federal requirements for screening people for mental illness or developmental disability (and subsequent referrals for more completed evaluation as needed) are limited to:

  • • A person who, having entered an acute care facility from a certified nursing facility, is returning to a certified nursing facility
  • • A person transferring from one certified nursing facility in Minnesota to another certified nursing facility in Minnesota
  • • Certain hospital discharges when:
  • • The person is entering a certified nursing facility directly from an acute care hospital after receiving acute inpatient care at the hospital
  • • The person requires NF services for the same condition for which he or she received care in the hospital
  • • The attending physician has certified before admission that the individual is likely to receive less than 30 days of NF services. ALL of these conditions must be met in order for an admission to be considered exempt from preadmission screening
  • Preadmission Screening for NF Level of Care Determination

    The determination of the need for nursing facility level of care shall be made according to criteria developed by the commissioner. In assessing a person's needs, screeners shall have a physician available for consultation and shall consider the assessment of the individual's attending physician, if any. The individual’s physician shall be included if the physician chooses to participate. Other personnel may be included on the team as deemed appropriate by the county agencies.

    Exemptions: Persons who are exempt from preadmission screening for purposes of level of care determination include:

  • • Persons exempt under the federal requirements related to screening for mental illness or developmental disability as outlined above
  • • An individual who has a contractual right to have nursing facility care paid for indefinitely by the veteran’s administration
  • • An individual who is enrolled in the Ebenezer/Group Health social health maintenance organization project, or enrolled in a demonstration project under MS 256B.69, subd. 8, at the time of application to a nursing facility
  • • An individual currently being served under the alternative care program or under a home and community-based services waiver authorized under section 1915(c) of the Social Security Act
  • An individual admitted to a certified nursing facility for a short-term stay, which, based upon a physician’s certification, is expected to be 14 days or less in duration, and who have been screened and approved for nursing facility admission within the previous six months. This exemption applies only if the screener determines at the time of the initial screening of the six-month period that it is appropriate to use the nursing facility for short-term stays and that there is an adequate plan of care for return to the home or community-based setting. If a stay exceeds 14 days, the individual must be referred no later than the first county working day following the 14th resident day for a screening, which must be completed within five working days of the referral. Payment limitations listed below will apply to an individual found at screening to not meet the level of care criteria for admission to a certified nursing facility.

    Individuals Under 21 Years of Age

    Exemptions outlined above DO NOT apply to people under age 21. Face-to-face assessment must occur before admission to an NF for all individuals under age 21, regardless of projected length of stay or admission source. At the face-to-face assessment, all community alternatives must be explored and presented to the person, his/her family, and/or the person's representative. If an NF admission cannot be prevented, the admission must be approved by the Department of Human Services (DHS) by calling 651-431-4300.

    Preadmission Screening and Medical Assistance Reimbursement

    Medical assistance reimbursement for nursing facilities shall be authorized for a medical assistance recipient only if a preadmission screening has been conducted prior to admission or the local county agency has authorized an exemption. Medical assistance reimbursement for nursing facilities shall not be provided for any recipient who the local screener has determined does not meet the level of care criteria for nursing facility placement or, if indicated, has not had an evaluation completed unless an admission for a recipient with mental illness is approved by the local mental health authority or an admission for a recipient with a development disability is approved by the state development disability authority.

    The nursing facility shall not bill a person who is not a medical assistance recipient for resident days that preceded the date of completion of screening activities as required under state and federal law. The nursing facility must include an unreimbursed resident day in the nursing facility resident day totals reported to DHS.

    Emergency Admissions

    Persons admitted to the Medicaid certified nursing facility from the community on an emergency basis as described in (1), or from an acute care facility on a nonworking day must be screened the first working day after admission.

    Emergency admission to a nursing facility prior to screening is permitted when a person is admitted from the community to a certified nursing or certified boarding care facility during county nonworking hours and:

  • • The physician has determined that delaying admission until preadmission screening is completed would adversely affect the person’s health and safety
  • • There is a recent precipitating event that no longer enables the client to live safely in the community, such as sustaining an injury, sudden onset of acute illness, or a caregiver is unable to continue to provide care
  • • The attending physician must authorize the emergency placement and document the reason that emergency placement is recommended
  • The county screener must be contacted on the first working day following the emergency admission.

    Transfer of a patient from an acute care hospital to a nursing facility is not considered an emergency except for a person who has received hospital services in the following situations: hospital admission for observation (i.e., stabilization of medications), or care in an emergency room without hospital admission, or following hospital 24-hour bed care.

    PAS Summary

    The table below summarized timelines and other requirements for preadmission screening as well as some follow-up activity performed by county Long Term Care Consultation staff.

    TIMELINES FOR PAS & ASSESSMENTS FOR NURSING FACILITY ADMISSIONS

    Preadmission Screening

    Under 65

    Over 65

    Hospital Discharge: NF Admission Meets Criteria for a 30-Day Exemption

    No PAS Required

    No PAS Required

    Inter-facility Transfer (NF-NF or NF-Acute Hosp-NF)

    No PAS Required

    No PAS Required

    Initial Admission Under a Qualifying 30-Day Exemption But Stay Exceeds 30 Days

    By 40th Day of Admission: Face-to-face LTCC visit, OBRA Level 1, any needed OBRA Level 2

    By 40th Day of Admission: Telephone screening or face-to-face; OBRA Level 1 and any needed OBRA Level 2

    Acute Hospital Discharge to NF: Stay Projected to be 30 Days or Longer, or Admission Doesn’t Meet Other 30-Day Delay Criteria

    Before Admission. May be telephone or face-to-face.

    If telephone: LTCC face to face visit must occur within 40 working days of admission.

    Before Admission: Telephone or face-to-face

    Admission from an acute hospital to NF on non-working county day

    Next work day after admission LTCC visit within 40 working days of admission if telephone screen

    Next work day after admission

    Initial screening after emergency NF admission

    Next work day after admission.LTCC visit within 40 working days of admission if telephone screen

    Next work day after admission

    Age 20 and under

    Face-to-face LTCC & DHS approval required for any admission to NF

    Required face-to-face assessment for persons age 21 to 64 admitted to NF if admitted by telephone screening

    Within 40 work days of admission

    County Responsibility

  • • Under certain circumstances, counties have the option to complete a PAS face-to-face or by telephone. PAS must be completed by a public health nurse and/or social worker
  • • The nursing facility must notify all applicants who request admission, and their families, that a PAS is required before admission. The nursing facility must also notify the county PAS screener of all new applicants
  • • Under most circumstances, the "county of location" is responsible for PAS for recipients requesting admission to a certified nursing facility or certified boarding care facility
  • • If the person leaves a correctional facility (on medical release) to enter a NF, the person must be screened by the county in which the prison is located
  • • If the person is being discharged from the hospital to the nursing facility, contact the county in which the hospital is located
  • Nursing Facility and Boarding Care Home Responsibility

    NFs and certified boarding care facilities' responsibilities under the PAS program include the following:

  • • Determining if applicant has been screened
  • • Informing applicants of PAS program requirements and background
  • • Obtaining consent for PAS and notifying the county
  • • Providing the screener with pertinent information obtained from the applicant or family
  • For further details on PAS, contact the PAS screener in your county or LTCC coordinator at DHS at 651-431-2759.

    The nursing facility should retain the following documents:

  • • PAS notice to resident that he/she has been screened
  • • Statement of applicant's choice for placement
  • • A copy of the Level I form signed by the screener
  • Covered Services

    MHCP covers room and board care for an MA recipient in a certified NF or certified boarding care facility. The care and monthly room and board services (per diem) cannot be billed until the beginning of the following month (e.g., January services cannot be billed until February 1).

    Items/services usually included in the per diem (not an all-inclusive list):

  • • Nursing services
  • • Laundry and linen services
  • • Dietary services
  • • Personal hygiene items necessary for daily personal care (e.g. soap, shampoo, toothpaste, toothbrush, shaving cream, etc.)
  • • Over-the-counter drugs or supplies used on an occasional, as needed basis (e.g. aspirin, acetaminophen, antacids, cough syrups, etc.)
  • Items/services not included in the per diem (not an all-inclusive list):
    MA covers the majority of costs incurred while in a nursing facility. However, a resident may be responsible for some non-covered MA services, such as:

  • • Special Services
  • • Other services not covered by MA
  • • Spenddown amounts
  • Additional Charges for Special Services

    State law allows a facility to charge residents for special services that are not included in the per diem. Special services must be available to all residents in all areas of the facility and charged separately at the same rate for the same services. In order to qualify as a special service, the following conditions must be satisfied for MA and private-pay residents:

  • • The facility must provide a detailed explanation of what is included in the case-mix rate
  • • The facility must provide a detailed explanation of the special service and the additional charge
  • • The cost of the special service must not have been included in the facility’s historical cost in the cost report for the prior reporting year
  • • The service cannot be a licensure or certification requirement
  • • Each resident or potential admission must be free to choose whether or not he/she desires to purchase the special service from the facility
  • • The facility must allocate and report the cost and charges associated with the provision of special services under unallowable costs in the facility’s annual cost report (for those required to file)
  • Questions regarding nursing facility services may be directed to:

    Long-Term Care Policy Center
    651-431-2282
    DHS.LTCpolicycenter@state.mn.us

    Rehabilitative Services

    Nursing Facilities may provide rehabilitative services to their residents and members of the community, utilizing either their own staff or by contracting with an outside service vendor (rehab agency). Services must be provided on the premises.

    The billing party may only bill physical therapy (PT), occupational therapy (OT), and speech-language pathology (SLP), if it is not a part of the facilities per diem. MHCP will not make separate reimbursement for therapy services for residents of a nursing facility that includes therapy as part of the per diem rate. The party designated to do the billing shall bill for all rehabilitative services. Refer to Rehabilitative Services for covered services.

    Note: The provider that bills for and receives payment for services is responsible for the accuracy of the claims and for maintaining patient records that fully disclose the extent of the benefits provided. Also, if Medicare requires the nursing facility to do the billing for Medicare covered rehabilitative services for dually eligible recipients; you must follow Medicare's requirements until Medicare benefits are exhausted.

    Leave Days (SNF/NF/BCH)

    Leave days are eligible for MA payment. A leave day must be for hospital leave or therapeutic leave of a recipient who has not been discharged from a nursing facility. A reserved bed must be held for a recipient on hospital leave or therapeutic leave. Payment for leave days in an SNF or NF is limited to 30% of the applicable payment rate.

    To be eligible for MA payment, the following criteria must apply:

    Hospital Leaves

  • • The recipient must have been transferred from a nursing facility to the hospital
  • • The recipient’s record must document the date the recipient was transferred to the hospital and the date the recipient returned to the nursing facility
  • • The hospital leave days must be reported on the claim submitted by the nursing facility with the appropriate hospital leave revenue code
  • Therapeutic Leaves

  • • The recipient's record must document the date and time the recipient leaves the nursing facility and the date and time of return
  • • The recipient may go on a home visit or vacation, to a camp that meets MDH licensure requirements, or to another residential setting except another nursing facility, hospital or other entity eligible to receive federal, state or county funds for his/her maintenance
  • • The therapeutic leave days must be reported on the claim submitted by the nursing facility with the appropriate therapeutic leave revenue code
  • Leave day Limitations

    Payment for hospital leave days is limited to 18 consecutive days for each separate and distinct episode of medically necessary hospitalization. Separate and distinct episode mean one of the following:

  • • The occurrence of a health condition that is an emergency
  • • The occurrence of a health condition that requires inpatient hospital services, but is not related to a condition which required previous hospitalization and was not evident at the time of discharge
  • • The repeat occurrence of a health condition that is not an emergency, but requires inpatient hospitalization at least two calendar days after the recipient’s most recent discharge from the hospital
  • MA payment for therapeutic leave days is limited to the number of days listed below:
    Recipients in an SNF or NF or certified boarding care facility are entitled to 36 leave days per calendar year.

    MA payment for leave days beyond the 18 or 36-day limit is prohibited, regardless of the occupancy rate. However, the resident or family may opt to pay the nursing facility to hold the bed beyond the MA benefit period, if the facility offers this special service. If a resident is on leave day status, under most circumstances the facility may not discharge the resident or fill the bed with another resident until after the 18 or 36-day leave period has elapsed, and not at all if the resident has elected to self-pay for days beyond the 18 or 36-day leave period. This policy applies regardless of the facility’s occupancy rate. MA residents that exhaust their hospital leave days and are subsequently discharged from the facility are entitled to be readmitted to the facility to the next available bed.

    Note: A 30-day notice may be required before a resident can be discharged due to leave days being exhausted, as provided in MS 144.652, subd.29.

    Determining the Number of Leave Days

    According to the definition of "leave day," an overnight absence of more than 23 hours is considered a leave day that must be reported. An absence of less than 23 hours on the first day is not a leave day. After the first 23 hours, each time the clock passes midnight counts as an additional leave day. Examples:

    LEAVE

    RETURN

    NUMBER OF LEAVE DAYS

    4:30 p.m. Friday

    11:30 a.m. Saturday

    0 (Less than 23 hours)

    4:30 p.m. Friday

    5:00 p.m. Saturday

    1 (More than 23 hours)

    4:30 p.m. Friday

    8:00 p.m. Sunday

    2 (More than 23 hours; past midnight once)

    4:30 p.m. Friday

    7:30 a.m. Monday

    3 (More than 23 hours; past midnight twice)

    Occupancy Rate

    Payment for hospital leave and therapeutic leave days are subject to the following occupancy rates:

  • • Nursing facilities with 25 or more licensed beds will not receive payment if the average occupancy rate was less than 96% during the month of leave
  • • Nursing facilities with 24 or fewer licensed beds will not receive payment if a licensed bed has been vacant for 60 consecutive days prior to the first leave day. (Date of death or discharge will be considered day one when counting consecutive days.)
  • • The nursing facility charge for a leave day must not exceed the charge for a leave day for a private paying resident in the same type of bed
  • The occupancy rate may be calculated separately for each level of care in the facility as follows:

  • • Determine the number of days each licensed bed was occupied during the month. (Note: A reserved bed is to be considered an occupied bed for this purpose.)
  • • Total to determine the number of occupied bed days for the month
  • • Divide by the number of days in the current month
  • • Divide by the number of licensed beds to determine the occupancy rate for the month
  • For questions on SNF/NF/BCH bed hold and leave day policy, contact:

    Long-Term Care Policy Center
    651-431-2282
    DHS.LTCpolicycenter@state.mn.us

    Private (Single Bed) Rooms in NFs

    To receive MA payment for a single bedroom for a MA recipient, the following requirements must be met:

  • • The single bed room must be located in a NF which has chosen to assign a greater proportion of their costs to single bed rooms
  • • The bed in the single bed room must be certified for MA by the MDH
  • • The recipient's attending physician must determine and certify that a single bed room is necessary because of a medical or behavioral condition that affects the health of the recipient or other residents
  • • The facility must estimate the length of time the private room is needed
  • • The facility’s Quality Assessment and Assurance Committee (QAAC) must recommend the single bed room and document the resident’s condition necessitating the single bed room
  • • The attending physician's signed statement, the QAAC's signed statement, and brief documentation of the recipient’s condition must be submitted to DHS for review (on a DHS request form
  • Include the above information on a DHS form and fax it to the number below. Refer to Requesting MA Payment for Private Rooms to access the form and obtain additional information.

    Department of Human Services
    Nursing Facilities Rates and Policy – Private Room Request
    Fax 651-431-7466

    Swing Bed Hospital Services (NF/Swing Beds)

    State law allows MA payments for swing bed services provided by a designated licensed hospital, if the following criteria are met:

  • • The hospital is the sole community provider, or is a public hospital owned by a government entity with 15 or fewer acute care beds
  • • The MA patient requires skilled nursing care per Medicaid guidelines
  • • A nursing home bed is not available within 25 miles of the facility
  • • The patient is transferred from an acute care hospital bed and acute care is no longer needed
  • • The person must receive a preadmission screening prior to placement as specified in the Preadmission Screening section of this section
  • • The hospital enrollment criteria, specified in Requirements for Providers
  • Eligible Provider

    To be eligible as a swing bed provider in the MA program, a provider must accomplish the following:

  • • Receive Medicare certification as a Medicare swing bed provider. Medicare certification requires a survey by the MDH. Certification information may be obtained from:
  • Minnesota Department of Health (MDH)
    Facility and Providers Compliance Division
    85 East 7th Place
    P.O. Box 64900
    St. Paul, MN 55164
    651-215-8701

  • • Sign a Swing Bed Provider Agreement with DHS. Provider agreement information may be obtained from:
  • Minnesota Department of Human Services
    Nursing Facilities Rates and Policy
    P.O. Box 64973
    St. Paul, MN 55164-0973

    Exceptions: Swing bed services may be billed by a hospital not enrolled in the MA program only in the case of a Qualified Medicare Beneficiary (QMB) receiving Medicare swing bed services. Coinsurance and deductible on QMB claims will be paid for the length of the Medicare approved stay. MA also covers up to 10 days of nursing care provided to a patient in a swing bed if:

  • • The patient's physician certifies that the patient has a terminal illness or condition that is likely to result in death within 30 days and moving the recipient would not be in the best interests of the recipient and the recipient's family
  • • A nursing home bed is not available within 25 miles of the facility
  • • An open bed is not available in any Medicare hospice program within 50 miles of the facility
  • Eligible Recipients

    To be eligible for swing bed payment, there must be documentation that the recipient requires a level of skilled nursing care consistent with admission to a nursing facility and no longer requires acute care hospital services. If the need for skilled nursing care cannot be documented, the services are not eligible for MA payment. A copy of the preadmission screening document must be attached to the claim.

    Preadmission Screening

    All persons seeking placement in a swing bed must be screened either through a community screening or through a telephone screening prior to admittance to a swing bed in accordance with the policy described in the Preadmission Screening (PAS) section of this chapter. Exceptions to PAS in swing bed placement are:

  • • Persons admitted from the community on a physician certified emergency basis or persons admitted on a county non-working day must be screened on the first county working day after admission
  • • Persons returning to a swing bed who entered an acute care facility from a swing bed
  • • Persons in a swing bed who are transferring to another swing bed in another facility
  • • Persons who have a contractual right to have their swing bed services paid for by the Veterans Administration
  • • Persons who are enrolled in the Ebenezer/Group Health Social HMO Project at the time of application to the swing bed
  • Limitations

    In accordance with state law, payment for swing bed services for an MA recipient is limited to 40 days, unless the Commissioner of MDH grants an extension. Approval for services in excess of 40 days must be requested in writing from MDH at least ten days before the end of the maximum 40-day stay. The extension approval must be attached to claims, which include service dates beyond the initial 40-day period. Eligible hospitals are allowed a total of 1,460 days of swing bed use per the state's fiscal year; (July 1 to June 30) provided that no more than 10 hospital beds are used as swing beds at any one time.

    Ancillary Services

    Routine care and services, similar to those provided in an NF, are included in the daily swing bed payment rate. All other covered services may be billed to the MA program. All ancillary services must be billed in accordance with the respective guidelines for the service, as outlined in the appropriate chapters of this manual.

    Billing Guidelines

  • • Room and board services must be billed in the 837I format using the hospital's NPI. The type of bill must be 281
  • • The daily room and board payment rate for swing bed services is set by law as the statewide average payment rate of all MA nursing facilities' per diem. This rate is computed annually, effective each July 1st
  • • Only non-over-the-counter (OTC) DHS formulary pharmacy services can be billed outside the room and board per diem. Stock medications and OTC products are not separately reimbursable.
  • • Ancillary services for Medicare eligible people must be billed to Medicare. If the services are not covered by Medicare, MHCP may be billed (fee-for-service recipients only)
  • Equalization

    State law prohibits nursing facilities from charging private-pay residents higher rates than those approved by DHS for MA recipients. The law also allows residents to be awarded three times the payments that result from a violation. For more information on Equalization and Special Services, refer to the section in this Chapter on "Special Services."

    Exceptions

  • • The Equalization Law does not apply to third party payers
  • • The Equalization Law may or may not apply to private paying residents in single bed rooms, depending on the cost allocation method for single bed rooms chosen by the facility on their annual cost report
  • Conditions of Participation

    Termination of Provider Agreement

    A nursing facility that chooses not to comply with the Equalization Law may voluntarily withdraw or involuntarily be withdrawn from the MA program. Under most of these circumstances, the provider becomes ineligible to receive payment under other state and county programs. Special laws apply to Nursing Facility providers that withdraw from the Medicaid program (contact the LTC Policy Center at 651-431-2282 for more information). If discharge of residents is necessary, discharge planning and relocation must be done in accordance with all provisions of state and federal Resident Rights and the state Resident Relocation Law.

    Segregation of MA Residents

    Partial certification or de-certification of a distinct part of an NF may result in the segregation of MA residents. These practices discriminate against residents based on their source of funding and may violate both the Equalization Law and anti-discrimination laws. DHS will not enroll facilities that stigmatize residents receiving public assistance or practice other forms of resident discrimination. Nursing facilities that intend to or have segregated MA residents will be investigated by DHS.

    Solicitation of Contributions

    Federal law prohibits soliciting contributions, donations, or gifts directly from MA residents or family members. General public appeals for contributions are not considered direct solicitation of MA residents or families. If an MA resident or family member makes a free-will contribution, the LTC provider is required to execute a statement for signature by the contributor and the LTC administrator, stating services provided in the nursing facility are not predicated upon contributions or donations and the gifts are free-will contributions.

    Change of Ownership

    The Social Security Act requires a nursing facility to promptly report any organizational or ownership changes to the Minnesota Department of Health (MDH) to maintain enrollment with MHCP.

    MDH will determine if the nursing facility continues to meet minimal state and federal standards under new ownership. MDH will submit copies of the certification to the nursing facility, DHS, and the county.

    When DHS receives notification of change of ownership, the Provider Enrollment Unit will terminate the MHCP provider records assigned to the previous owner. The new owner must submit a new application and agreement to the Provider Enrollment Unit for a new MHCP enrollment.

    DHS will forward the new MHCP enrollment information to the county. The county will update its records and reassign MA recipients with the new provider enrollment information.

    According to state law, the owner of the nursing facility is liable for any overpayment amount owed by a former owner for any facility sold, transferred, or reorganized.

    Resident Trust Account

    Administration of Resident Fund Accounts

    A nursing facility resident may deposit his/her funds, including the personal needs allowance established under Minnesota statutes, in a resident fund account administered by the facility. A nursing facility must comply with MDH regulations concerning resident funds in addition to the following provisions:

  • • Credit to the account all funds attributable to the account including interest and other forms of income
  • • Not co-mingle resident funds with the funds of the facility
  • • Keep a written record of the recipient’s resident fund account, including the date, amount, and source of deposit or withdrawal recorded within five working days of the account activity
  • • Require a recipient who withdraws $10.00 or more at one time to sign a receipt for the withdrawal. A withdrawal of $10.00 or more that is not documented by a receipt must be credited to the recipient's account. Receipts for the actual item purchased for the recipient's use may substitute for a receipt signed by the recipient
  • • Not charge the recipient a fee for administering the recipient's account
  • • Not solicit donations or borrow from a resident fund account
  • • Report and document to the county a recipient's donation of money to the facility when the donation equals or exceeds the statewide average MA payment for SNF care
  • • Not use resident funds as collateral for or payment of any obligations of the facility
  • • Treat funds remaining in a recipient's account upon death or discharge as required by MDH regulations
  • Limitations on Use of Trust Funds

    Funds in the recipient's resident fund account must not be used to purchase the following items or services generally reported in the facility's cost report:

  • • Medical transportation
  • • Initial purchase or replacement purchase of furnishings or equipment required as a condition of certification as a nursing facility
  • • Laundering the recipient’s clothing
  • • Furnishings or equipment not requested by the recipient for personal convenience
  • • Personal hygiene items necessary for daily personal care (e.g., bath soap, shampoo, toothpaste, toothbrushes, dental floss, shaving cream, razor, facial tissues)
  • • Over the counter drugs or supplies used by the recipient on an occasional, as needed basis, not prescribed for long-term therapy of a medical condition (e.g., aspirin, acetaminophen, antacids, anti-diarrheas, cough syrups, rubbing alcohol, talcum powder, body lotion, petroleum jelly, mild antiseptic solutions, etc.)
  • These limitations do not prohibit the recipient from using his/her funds to purchase a brand name supply or other furnishings not routinely supplied by the nursing facility.

    Questions on LTC policy and services may be directed to:

    Long Term Care Policy Center
    Department of Human Services
    P.O. Box 64973
    St. Paul, MN 55164-0973
    651-431-2282

    Definitions

    Certified Bed: A bed certified under Title XIX of the Social Security Act.

    Certified Nursing Facility (NF): A facility or part of a facility which is licensed to provide nursing care for persons who are unable to properly care for themselves

    Demand Bill: A claim sent to Medicare that the resident's family or other interested party requests to receive a decision from Medicare regarding the status of a claim.

    Discharge: Termination of placement in the NF that is documented in the discharge summary and signed by the physician.

    Facility with Distinct Part Certification: Sections of the facility certified as psychiatric, NF, or ICF/DD; must admit and care for those MA recipients certified as requiring the same level of care as the bed certification.

    LTC Facility: A residential facility certified by the MDH as a skilled nursing facility or as an intermediate care facility, including an ICF/DD.

    Leave Day: An overnight absence of more than 23 hours. After the first 23 hours, additional leave days are accumulated each time the clock passes midnight. Absence must be for hospital or therapeutic cause.

    Reserved Bed: The same bed that a recipient occupied before leaving the facility for hospital leave or therapeutic leave, or an appropriately certified bed if the recipient's physical condition upon returning to the facility prohibits access to the bed he/she occupied before the leave. Commonly referred to as “bed hold”.

    Short-term Stay: Nursing facility admission expected to be less than 14 days.

    Swing Bed: A hospital bed that has been granted a license under MN Statutes 144.562 and which has been certified to participate in the federal Medicare program under US code title 42, section 1395. Refer to the Swing Bed section of this chapter.

    Transfer: Temporary disposition of a resident, for whom a bed is being held, to an inpatient hospital.

    Legal References

    MS 144.562, subd.2 & 3 - Swing Bed Approval
    MS 256B.27
    , sub.1 - Medical Assistance; Cost Reports
    MS 256B.0625
    , subd.2 - Covered Services
    MS 256B.0911
    , - Long-Term Care Consultation Services
    Minnesota Rules 9505.0410 to 9505.0420
    , - TC; Rehabilitative and Therapeutic Services
    Minnesota Rules 9549.0010 to 9549.0080
    , - Nursing Facility Payment Rates
    MS 256B.48
    , - Conditions for Participation
    MS 256B.501
    , - Rates for Community-Based Services for Disabled
    Minnesota Rules 9549.0060
    , subp.11 - Determination of the Property Related Payment Rate
    Minnesota Rules 9549.0070
    , subp.3 - Computation of Total Payment Rate

    CPT codes, descriptions and other data only are copyright 2002 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Apply.

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