Bed Reservation BML Questions - Round 3

NOTE: Questions that were answered in response to previous posts are not duplicated here. Please refer to the Q&A's that were posted on July 19, 2010, August 13, 2010 and November 3, 2010.

1. Our facility has both vent and non-vent beds. I would like clarification of the following:

a) Currently the 95% threshold census requirement for bed hold is calculated separately for vent and non-vent units. Is a resident entitled to 14 days in the vent unit and if they are weaned get another 14 days in the non-vent unit? Again, since the requirement is to treat as 2 separate facilities, then I believe they should get 14 days for each level of care.

A resident eligible for Medicaid reserved bed days is granted 14 hospitalization days and 10 leave of absence days per 12-month period, regardless of transferring to another unit within the same facility.

b) We recently had a situation where a non-vent resident went to the hospital. While in the hospital, on day 10, we found out that the patient now has a vent. Do we discharge the patient because they no longer qualify for the bed we are holding?

As outlined in 18 NYCRR section 505.9(d)(6), the nursing home and hospital must maintain communication during a recipient's period of temporary hospitalization. Such communication must include information regarding the recipient's reserved bed status at the nursing home as well as any changes in the recipient's condition during the reserved bed period. Upon learning that a recipient's reserved bed would no longer meet that recipient's needed level of care, the bed may be released for a new admission and the recipient would be given priority in readmission to the facility should an appropriate bed become available.

My grandmother is a resident at a nursing home and was admitted to the hospital. According to the nursing home, her 14 days will be up on Saturday. In order to keep her bed, we will have to pay $350.00 a day. Since she has been there for almost three years, can they do this or do they have to keep a bed available for her no matter what?

If a Medicaid-eligible resident's temporary hospitalization or leave of absence exceeds the number of Medicaid reimbursable days, the facility may charge privately for the bed to be held. However, the Department does not regulate the amount a facility may charge to interested parties who wish to pay privately to hold a bed.

3. a) Is it true that when the 14 Medicaid bed hold days are exhausted, the facility can discharge the resident?

No, it is not true. The resident is not considered discharged when bed hold days are exhausted. The bed is released for purposes of reimbursement, and is considered to be vacant and open for a new admission. The resident must be given priority readmission status for the next available bed in the facility. A resident may be discharged only under the following circumstances:

  • Transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met after reasonable attempts at accommodation in the facility;
  • Transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; or
  • The health or safety of individuals in the facility would otherwise be endangered, the risk to others is more than theoretical and all reasonable alternatives to transfer or discharge have been explored and have failed to safely address the problem.
  • Transfer and discharge shall also be permissible when the resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare, Medicaid or third party insurance) a stay at the facility. For a resident who becomes eligible for Medicaid after admission to a facility the facility may charge a resident only allowable charges under Medicaid. Such transfer or discharge shall be permissible only if a charge is not in dispute, no appeal of a denial of benefits is pending, or funds for payment are actually available and the resident refuses to cooperate with the facility in obtaining the funds;
  • Transfer or discharge shall also be permissible when the facility discontinues operation and has received approval of its plan of closure from the Commissioner of Health.

3. b) Is it allowable for a facility to ask a resident on Medicaid to pay privately to continue holding their bed?

If a Medicaid-eligible resident's temporary hospitalization or leave of absence exceeds the number of Medicaid reimbursable days, the facility may charge privately for the bed to be held. However, the Department does not regulate the amount a facility may charge to interested parties who wish to pay privately to hold a bed.

4. A resident is hospitalized and is not eligible for a bed hold due to occupancy requirements. The resident subsequently notifies the facility they do not wish to return and they are placed elsewhere. If they are re-hospitalized prior to establishing residency at the new facility, is the first facility obligated to take them back?

In the scenario above, the patient would be considered "voluntarily discharged" and the facility would not be obligated to offer them priority readmission.

5. Will exceptions be made for additional leave of absence reserved bed days for New York State Medicaid-eligible nursing home residents currently placed out of state that wish to come home to visit family and friends?

No, the law does not allow for exceptions to the total number of reimbursable reserved bed days for periods of temporary hospitalization or non-hospitalization leaves of absence in a 12-month period.

6. I only became aware of the new bed reservation policy yesterday, but have several questions:

a) Are "Dear Administrator Letters" actually sent to providers, or only posted on the NYSDOH web site?

All nursing home administrators receive "Dear Administrator Letters" electronically. They can be found on the Department's website, and also on the Health Commerce System.

b) Have the changes been made in the eMedNY system to cap the leaves? I don't believe I have seen R/A showing that a claim has been denied due to a bed hold being exhausted?

The Department is working to update the eMedNY system to reflect the statutory changes impacting the reserved bed day policy.

7. What happens when a patient is transferred and admitted to the hospital, and the facility is not at 95% (hence the patient is not put on bed hold), but a few days later the facility has a few admissions which put them at 95% occupancy or above. Can the patient now be picked up on bed hold?

No. In accordance with 18 NYCRR section 505.9(d)(5)(i)(b), a facility may bill Medicaid for a bed reservation when the part of the facility the recipient will return to has a vacancy rate of no more than 5 percent on the first day the recipient is hospitalized or on a non-hospitalization leave of absence.

8. I would like to confirm an assumption we have on the 12-month period for existing residents: The scenario is that a resident has met the residency requirements, have completed their 12-month period and are still in the same facility. Our assumption is that there is no need to re-establish residency since the resident never left the facility so the 12-month period would begin the day after the previous 12-month period ended and the number of reserved bed days will be reset to zero. Example: A resident's 12-month period is from July 19, 2010 to July 18, 2011. The next period would be July 19, 2011 to July 18, 2012.

Correct, residency does not need to be re-established if the resident is still in the same facility at the end of their 12-month period. The new 12-month period begins the day after the previous 12-month period ended, and the resident's number of Medicaid reimbursable reserved bed days is reset to 14 hospitalization days and 10 leave of absence days.

9. I have a few questions regarding the new bed reservation regulations for RHCFs.

a) Does residency start the 31st day or the 30th day? My understanding is that a Medicaid resident's bed hold for reimbursement would begin on the 31st day, however, our biller states that she often hears the question from Medicaid, "Have they been here 29 days?"

In general, a recipient must be a resident of a facility for 30 days since the date of initial admission before Medicaid will reimburse for reserving the recipient's bed. Therefore, residency would be established at the end of the 30th day. Further, Medicaid may only be billed for reserved bed days if the residency requirement is met and Medicaid was the primary payor on at least one of those days.

b) If a Medicaid resident has met the residency requirements and transfers to the hospital October 1st, uses their 14 bed hold days, is discharged, and then is admitted direct from the hospital on November 1st, does their new 12-month period start on November 1st or do they need to wait 30 days again for residency? Number 9 in the questions and answer section from the August 13th Dear Administrator letter states that if a resident used up the 14 bed hold days and was discharged home or to another RHCF and was readmitted to the original nursing home, that the resident would have to establish residency again. It does not state if they would have to establish residency again or not if they returned directly from the hospital.

In the event that a Medicaid eligible resident's hospitalization exceeds 14 days, and the bed reservation is terminated, the resident is not discharged. They must be given priority readmission to their original facility. If the recipient is subsequently readmitted to the original facility directly from the hospital, residency does not need to be re-established.

c) Is there a recommended form for tracking when each resident's 12-month period begins (which will be after they have established residency), when their 12-month period ends, and the number of hospital and therapeutic LOA days used in the current 12-month period?

The Department will not be developing a form for tracking each resident's 12-month period and/or number of available reserved bed days. Facilities are expected to maintain appropriate documentation to coincide with their own policies and procedures.

10. If the resident's entire stay is covered by Medicare with a Medicaid co-insurance, can the stay be counted toward the resident's residency requirement? Also, can Medicaid be billed for a bed hold?

The residency requirement is met, regardless of payment source, when the resident has lived in the facility for 30 days. Medicaid cannot be billed for the reserved bed unless the residency requirement is met and Medicaid was the primary payor on a least one day.