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.
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:
Specifications are in the Swing Bed section.
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:
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:
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.
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:
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:
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.
A nursing facility may employ an individual working in the facility as a nursing assistant for more than four months, if the individual:
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:
A nursing facility may employ a non-permanent (temporary or contract) employee working in the facility as a nursing assistant, if the individual:
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.
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.
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
For questions related to nurse aide reimbursement policies, contact:
Long-Term Care Policy Center
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.
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:
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:
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.
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.
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.
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 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.
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
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.
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
NFs and certified boarding care facilities' responsibilities under the PAS program include the following:
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:
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):
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:
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:
Questions regarding nursing facility services may be directed to:
Long-Term Care Policy Center
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 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:
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:
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.
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:
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)
Payment for hospital leave and therapeutic leave days are subject to the following occupancy rates:
The occupancy rate may be calculated separately for each level of care in the facility as follows:
For questions on SNF/NF/BCH bed hold and leave day policy, contact:
Long-Term Care Policy Center
To receive MA payment for a single bedroom for a MA recipient, the following requirements must be met:
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
State law allows MA payments for swing bed services provided by a designated licensed hospital, if the following criteria are met:
To be eligible as a swing bed provider in the MA program, a provider must accomplish the following:
Minnesota Department of Health (MDH)
Facility and Providers Compliance Division
85 East 7th Place
P.O. Box 64900
St. Paul, MN 55164
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:
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.
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:
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.
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.
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."
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.
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.
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.
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.
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:
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:
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
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.
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
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