Nursing Facilities
Overview
The Minnesota Department of Human Services (DHS) is responsible for developing and interpreting policy and the administration of Medicaid programs impacting Minnesota nursing facilities and board and care homes that are enrolled with Minnesota Health Care Programs (MHCP). DHS also develops and implements rates and policies regarding nursing facility services, quality of care and transitions to and from a nursing facility. DHS focuses on the quality of care and services provided to MHCP members living in nursing facilities, and provides information and resources related to nursing facilities and nursing facility care.
Eligible Providers
To be eligible to provide services for Long Term Care, providers must meet the requirements and submit the forms listed on the Nursing Facility Enrollment Criteria and Forms provider enrollment page. Enrolled skilled nursing facilities (SNF), nursing facilities (NF) or board and care homes (BCH) licensed as nursing facility providers by MDH are eligible to provide services and bill for MHCP. See the Swing Bed Hospital Services (Nursing Facility Swing Beds) section of the Provider Manual for information about eligibility requirements for swing bed providers.
Eligible Members
Nursing facilities provide services to individuals who have been screened and determined to need a nursing facility level of care.
MA eligible members must reside in a Medicaid certified bed in order for their stay to be considered for payment by MHCP. For more long term care eligibility requirements, refer to your county financial worker.
MHCP covers the cost of care for a member who resides in a certified NF or certified BCH if the certified NF or certified BCH meets the following requirements:
Physician Certification
A physician must certify the need for a certified NF or certified board and care facility. Providers must complete the Physician Certification (DHS-1503) (PDF) form 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) (PDF).
The staff at the facility must complete the Physician Certification form within 30 days before 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 Board and Care Members
Under state rule, a member must have a current admission medical history and complete physical examination performed and recorded by a physician, physician assistant or nurse practitioner within five days before or within seven days after admission. After the admitting examination, the physician must see the member at least every 30 days for the first 90 days after admission and then every 60 days, or sooner when medically necessary. A physician visit is considered timely if it occurs within 10 days after the date the visit was required.
When a member 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 member returns from the hospital.
Members 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 members at least every six months and board and care home members at least once per year. Each refusal must be documented in the member’s medical record and signed by the member and the physician.
Preadmission Screening (PAS) under State and Federal Laws
Federal and state laws require preadmission screening (PAS) for all people prior to entering a Medical Assistance-certified nursing facility, certified board and care facility or hospital swing bed. In Minnesota, the PAS is submitted to the Senior Linkage Line and includes both nursing facility level of care determination and screening people for developmental disabilities or mental illness, referred to as OBRA Level I screening. In addition, nursing facility members on MA must have their level of care established at admission and 90 days after admission. Refer to the Minnesota Senior Linkage Line for the state’s PAS policies and related procedures.
Preadmission Screening for Mental Illness or Developmental Disability
An OBRA Level II evaluation is needed when a person is suspected to have or has a confirmed diagnosis of a serious mental illness or a developmental disability or related condition and is seeking admission to a nursing facility. The lead agency must complete the OBRA Level II prior to nursing facility admission.
Questions regarding OBRA Level II or resident reviews for Developmental Disabilities:
Questions regarding OBRA Level II or resident reviews for Mental Illness (MI):
Nursing Facility and Board and Care Home Responsibility
NFs and certified Board and Care facilities' responsibilities under the PAS program include the following:
For further details on PAS, contact the Minnesota Senior LinkAge Line at 800-333-2433.
Covered Services
MHCP covers room and board care for an MA member 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 (for example, January services cannot be billed until February 1).
Items and services usually included in the per diem (not an all-inclusive list):
Leave Days (SNF/NF/BCH)
Leave days are eligible for MHCP payment. A leave day must be for hospital leave or therapeutic leave of a member who has not been discharged from a nursing facility. A reserved bed must be held for a member on hospital leave or therapeutic leave. Payment for leave days in an SNF or NF is limited to 30 percent of the applicable payment rate.
To be eligible for MHCP payment, the following criteria must apply for each leave type:
Hospital Leaves
Therapeutic Leaves
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.
Number of 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:
The occupancy rate may be calculated separately for each level of care in the facility as follows:
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 means one of the following:
MHCP payment for therapeutic leave days is limited to 36 leave days per calendar year for members in an SNF or NF or certified boarding care facility.
MHCP payment for leave days beyond the 18 or 36-day limit is prohibited, regardless of the occupancy rate. However, the member or family may opt to pay the nursing facility to hold the bed beyond the MHCP benefit period, if the facility offers this special service. If a member is on leave day status, under most circumstances the facility may not discharge the member or fill the bed with another resident until after the 18 or 36-day leave period has elapsed, and not at all if the member has elected to self-pay for days beyond the 18 or 36-day leave period. MA members 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 member can be discharged due to leave days being exhausted, as provided in Minnesota Statutes, 144.652, subdivision 29.
For questions on SNF, NF or BCH bed hold and leave day policy, contact:
Long-Term Care Policy Center
DHS.LTCpolicycenter@state.mn.us
Private (Single Bed) Rooms in NFs
To receive MHCP payment for a single bedroom for a MA member, NFs must meet the following requirements:
Complete Private Room Request (DHS-8164) (PDF) and fax to:
Department of Human Services
Nursing Facilities Rates and Policy – Private Room Request
Fax: 651-431-7466
Noncovered Services
Items and services not included in the per diem (not an all-inclusive list):
MHCP covers the majority of costs incurred while in a nursing facility. However, a member may be responsible for some noncovered MHCP services, such as:
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 members in all areas of the facility and charged separately at the same rate for the same services. To qualify as a special service, the following conditions must be satisfied for MA and private-pay members:
Direct questions about nursing facility services to:
Long-Term Care Policy Center
DHS.LTCpolicycenter@state.mn.us
Discharge and Transfer
When a member is discharged, they are terminated from a residential treatment period of care through the formal release or death of the member. 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 member returns to the facility, all admission record requirements must be completed to be eligible for Medical Assistance payment.
When a member is transferred, they are temporarily placed into an inpatient hospital (not including regional treatment centers or other nursing facilities) and the facility holds the bed for the member. The medical record must indicate the member was absent from the facility and upon return must be updated with any changes.
In addition, any transfer, discharge or relocation of members must comply with all applicable federal or state laws, including the state Resident Relocation law.
Medicare and Other Insurance
Medicare and other insurance is considered primary to Medical Assistance. If the member is receiving a Medicare benefit or other Third Party Liability insurance (TPL), that information must be entered on the header level of the Coordination of Benefits screen when submitting Room and Board claims. Refer to the Medicare and Other Insurance portion of the Provider Basics section under Billing Policy Overview.
Exceptions for Prepaid Health Plans
For nursing home members who have both MA and a Prepaid Medical Assistance Program (PMAP), and have exhausted their 180 days of managed Medicaid days, the nursing facility provider must fax the Nursing Facility (NF) Communication Form (DHS-4461) (PDF) to a member’s managed care plan to notify the plan of this change. The managed care plan will fax the Nursing Facility Communication Form to DHS at 651-431-7548 and send copies to the nursing facility. The state Equalization Law prohibits nursing facilities from charging private-pay residents higher rates than those approved by DHS for MA members. 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 on this page on Additional Charges for Special Services.
Exceptions to the Equalization Law:
Spenddown Refund Requests
Members residing in a nursing facility who have an LTC spenddown are obligated to pay the nursing facility their LTC spenddown amount.
When a member is also covered by Medicare Part A, the member may receive a refund for a portion of the LTC spenddown amount due to Medicare payments the nursing facility receives after the member has already paid the LTC spenddown. The nursing facility may retain the refund amount for payment of a past due obligation but only with the agreement of the member. Follow the Instructions for spenddown refund request for Long-term Care (DHS-4277A) (PDF) to apply for a spenddown refund.
Prohibited Practices
Certain practices, including, but not limited to the following are considered prohibited practices and violations could result in penalties to the provider:
Refer to Minnesota Statutes, 256R.04 for more details.
Billing
Resident Classification System
Case Mix rates paid by MHCP to approved providers are determined by the Minnesota Department of Health. For information on how the case mix system works, refer to the Minnesota Case Mix Review Program. For Information on the Short Stay Rate (DDF), Penalty Rate (AAA), other case mix related questions and contact information, refer to Case Mix Information for Providers.
Billing for Custodial Care
Do not bill for the care and monthly room and board services (per diem) until the beginning of the following month (for example, January services cannot be billed until February 1).
Bill as follows:
Review the MN-ITS User Manual for LTC Services for instructions on completing a LTC claim.
Billing for Rehabilitative Services
Nursing facilities may provide rehabilitative services to members 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. The party designated to do the billing will bill for all rehabilitative services. Refer to Rehabilitative Services for covered services.
Billing for Swing Bed Services
See Swing Bed Hospital Services (Nursing Facility Swing Beds).
Information on Nurse Aide Reimbursement
For questions related to nurse aide reimbursement policies, contact:
Long-Term Care Policy Center
DHS.LTCpolicycenter@state.mn.us
Nursing Assistant Registry
The Minnesota Nursing Assistant Registry lists nursing assistants who have met Minnesota training and testing standards to work in nursing homes and certified board and care homes. The registry also has information about nursing assistants who have substantiated findings of abuse, neglect and theft.
Nursing assistants, employers and others can search the registry at the Minnesota Nursing Assistant Registry Search (state.mn.us) website. You can search by entering a first name, last name and date of birth or the nursing assistant's certificate number.
Administration of Resident Trust Account Funds
A nursing facility member may deposit his or her funds, including the personal needs allowance established under Minnesota statutes, in a resident trust account fund administered by the facility. A nursing facility must comply with MDH regulations concerning resident funds in addition to the following provisions:
Limitations on Use of Resident Trust Account Funds
Do not use funds in the member's resident trust account fund to purchase the following items or services generally reported in the facility's cost report:
These limitations do not prohibit the member from using his or her funds to purchase a brand-name supply or other furnishings not routinely supplied by the nursing facility.
Direct questions on LTC policy and services to:
Long-Term Care Policy Center
Department of Human Services
P.O. Box 64973
St. Paul, MN 55164-0973
DHS.LTCpolicycenter@state.mn.us
Cost Reporting
Nursing facilities in Minnesota must file a cost report with DHS by Feb. 1 of each year. A facility’s cost report covers the previous reporting year, which runs from Oct. 1 to Sept. 30. DHS uses these cost reports to calculate a facility’s rate for the following rate year. The rate year runs from Jan. 1 to Dec. 31. This can be accessed in the Nursing Facility Provider Portal.
Definitions
Certified nursing facility (NF): A facility or part of a facility which is licensed to provide nursing care for individuals who are unable to properly care for themselves.
Demand bill: A claim sent to Medicare that the member’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 members certified as requiring the same level of care as the bed certification.
LTC facility: A residential facility certified by 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 member occupied before leaving the facility for hospital leave or therapeutic leave, or an appropriately certified bed if the member's physical condition upon returning to the facility prohibits access to the bed the member 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 Minnesota Statutes, 144.562 and which has been certified to participate in the federal Medicare program under 42 U.S.C. section 1395. See the Swing Bed Hospital Services (Nursing Facility Swing Beds) section of the Provider Manual.
Transfer: Temporary disposition of a resident, for whom a bed is being held, to an inpatient hospital.
Legal References
Minnesota Statutes, 256B.27, subdivision 1 (Medical Assistance; Cost Reports)
Minnesota Statutes, 256B.0625, subdivision 2 (Covered Services; Skilled and intermediate nursing care)
Minnesota Statutes, 256B.0911 (Long-Term Care Consultation Services)
Minnesota Statutes, 256B.48 (Conditions for Participation)
Minnesota Statutes, 256B.501 (Rates for Community-Based Services for Disabled)
Minnesota Statutes, 256R.42 (Rate Adjustment for the First 30 Days)
Minnesota Statutes, 256R.04 (Prohibited Practices)
Minnesota Statutes, 144A.161 (Nursing Home and Boarding Care Home Resident Relocation)
Minnesota Rules, 9505.0410 to 9505.0420 (Long-Term Care Facilities; Rehabilitative and Therapeutic Services)
Minnesota Rules, 9549.0010 to 9549.0080 (Nursing facility payment rates)
Minnesota Rules, 9549.0060, subpart 11 (Determination of the Property-Related Payment Rate; Capacity days)
Minnesota Rules, 4658.0710, subpart 4 (Physician visits)
Code of Federal Regulations, 483.30(c) (Physician services; Frequency of physician visits)
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