Questions and Answers on Reserved Bed Day Reimbursement to RHCFs for Medicaid Eligible Individuals Aged Twenty-One or Older

QUESTIONS and ANSWERS ON BED RESERVATION POLICY REVISIONS
Revised August 13, 2010

The law that authorizes the limits on bed hold payments [PHL Section 2808(25)] defines a "reserved bed day" as "a day for which a governmental agency pays a residential health care facility to reserve a bed...". Is the facility required to reserve a bed only if it is reimbursed for doing so?

Yes, the provider is only responsible to reserve the specific bed(s) for which payment is being rendered. Residents would be eligible for priority readmission pursuant to existing regulations under 10 NYCRR Section 415.3(h)(2)(v)(4)(iv), "a nursing home shall establish and follow a written policy under which a resident who has resided in the nursing home for 30 days or more and who has been hospitalized or who has been transferred or discharged on therapeutic leave without being given a bed-hold is readmitted to the facility immediately upon the first availability of a bed in a semi-private room if the resident: (a) requires the services provided by the facility; and (b) is eligible for Medicaid nursing home services.

Existing regulations at 18 NYCRR 505.9(d)(4) establish several conditions that must be met for payment of reserved bed days including, but not limited to, minimum residency of 30 days; vacancy rate of no more than 5 percent; and prior residency if Medicare is the primary payor at the time of discharge. Is this still the case?

Yes, this is still the case.

Are there circumstances under which a bed will not be reserved and the resident must be given priority in readmission?

Yes, if there is no bed reservation or the resident's bed reservation days have been exhausted, the facility is obligated to have the resident return to the next available semi-private bed.

10 NYCRR 86-2.8(d) indicates that reserved bed days should be computed separately, and goes on to define a reserved bed day as one for which the patient or his payor reimburses. How will vacancy rate calculations take into account paid and unpaid reserved bed days for hospitalization and therapeutic leave?

If a bed is being reserved with payment, it is considered to be occupied. If payment is not being rendered, the bed is considered vacant.

The regulations require that a resident must have lived in a facility for 30 days prior to hospitalization, with at least one full day reimbursable by Medicaid. Has this requirement been rescinded?

No, this requirement has not been rescinded and it still applies.

For a resident who is Medicaid-pending, when does his/her 12-month period begin?

The 12-month period begins when the residency requirement is satisfied.

When does the 12-month clock start for in-house residents – 7/19/10 or the first day a resident is hospitalized after July 19th?

July 19, 2010.

If the resident has used up their entire allotment of reserved bed days, is the resident considered on bed hold (assuming the facility is over 95% occupied) OR not considered on bed hold and given priority readmission status?

The resident is not considered on bed hold. The resident must be given priority readmission status. This applies to residents twenty-one years of age and older.

If a resident used up the 14 bed hold days and then was discharged to home or to another RHCF, and then was readmitted to the original nursing home within the 12 months, does the 12-month clock restart in the original nursing home?

Yes, after the newly readmitted resident has satisfied the residency requirement.

Are the annual limits of 14 days and 10 days applicable only when Medicaid makes payment, or will bed hold days paid for privately (including those that may be paid voluntarily by or on behalf of a Medicaid recipient) be counted against these limits?

The facility is obligated to hold the resident's bed for all days reimbursed under Medicaid or private funds. Private pay days are not counted as Medicaid bed reservation days, and as such are not counted against the 12 month limits.

Will any flexibility be accorded to facilities that serve greater numbers of medically complex individuals who are more prone to hospitalizations (e.g., ventilator units)?

No. The law does not allow any flexibility.

Is there a CMS State Plan Amendment requirement? If so, has it been filed?

Yes, a State Plan Amendment is required and has been filed.

Will Medicaid continue to pay the cash receipts assessment add-on to a facility only during the 14-day and 10-day limitation periods (i.e., when bed hold reimbursement is available)?

Yes. The Cash Receipts rate code can only be billed when there is a corresponding nursing home rate code billed.

Once a resident is discharged to a new location (i.e. new RHCF, home) must a new 30 day residency be established?

Yes. A recipient must be a resident of a facility for 30 days since the date of initial admission before reimbursement is available for bed reservation. Days do not have to be consecutive but must be within the same facility to be considered a valid period of residency.

When will the 5% reduction in the rate for bed hold days take effect?

The 5% reduction in the rate for bed hold is retroactive to April 1, 2010.

Regarding the 5% reduction in Bed hold rates retroactive to April 1, 2010, will Computer Science Corp. (CSC) initiate automatic retroactive rate adjustments, or should facilities adjust current Bed Hold claims for the rate reduction?

Claims processing will calculate the 95% reduction for bed hold claims. For bed hold claims already processed at 100%, from 4/1/10 forward, claims processing will generate a retro recoupment amount.

Does the 95% Bed Hold payment rate apply to the assessment (rate code 3836) as well?

No, the rate code amount for cash receipts assessment will not be adjusted because of this change.

How should non-billable Bed Hold days be reported on the RHCF-4? (We assume they would not be considered a patient day.)

The new law changes the reserved bed day policy for residential health care facilities to 14 days for temporary hospitalizations and 10 days for non-hospitalization leave. Providers should only report the actual bed hold days billed on the RHCF-4 cost report.

Will Medicaid continue to pay the cash receipts assessment add-on to a facility only during the 14-day and 10-day limitation periods (i.e., when bed hold reimbursement is available), or can this rate code be billed for uncompensated bed hold days? Will this add-on also be reduced by 5%?

Yes, cash receipts assessment billing is only applicable for 14 day and 10 day bed hold limitation. Cash receipt assessment billing is not applicable for "uncompensated bed hold days" since they can no longer be billed. No, the rate code amount for cash receipts assessment will not be adjusted because of this change.

Will a separate rate code be provided, or will facilities be required to manually adjust their billings for bed hold days?

There will be no change to the current rate codes because of the new law. Claims processing will calculate the 95% reduction for bed hold claims.

Please provide clarity on how nursing homes should bill after the revised bedhold provisions were put into place. For instance, would the State be issuing revised rate codes so that a facility may bill 95% of the rate for purposes of the bedhold?

There will be no change to the current rate codes because of the new law. Claims processing will calculate the 95% reduction for bed hold claims.

In the interim, could the State provide guidance on how a facility should bill for bedhold -- is it the standard rate code representing 100% of the existing rate (and then the State would reimburse just 95% of the billed amount)?

There will be no change to the current rate codes because of the new law. Claims processing will calculate the 95% reduction for bed hold claims.

Will the State confirm that separate bed-hold rate codes will be generated for each type of specialty (geriatric, ventilator, AIDS, etc)?

There will be no change to the current rate codes because of the new law.