Bed Reservation BML Questions - Round 2

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

1. Is it correct to assume that there is no longer the 5-day "grace" period which was in place for those residents who appeared to be able to return from the hospital to the nursing home within that time?

Yes, that is correct. The 5 day grace period no longer applies.

Can facilities allow more than 10 therapeutic leave days in a 12 month period if the clinical care team determines that it is in the resident's best interest?

If the resident's care plan documents the need for more than 10 therapeutic leave days in a 12-month period, the facility may allow additional visits, but will only be reimbursed for 10 therapeutic leave days per year.

2. With the 5% reduction retroactive to April 1, 2010, will nursing homes be required to make the adjustment for those days already billed and paid, or will the amount be automatically deducted from future payments?

Nursing homes cannot make any "adjustments" for bed hold claims already billed and paid at 100%. The amount will be deducted from future payments. 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.

3. If a resident returns to the facility as a priority readmission after a bed hold expires, do they qualify for another 14 days of bed hold for temporary hospitalization in the upcoming 12 month period as they would if they went to another facility?

Residents who are hospitalized and readmitted to the same facility based on priority readmission are not eligible for another 14-day bed reservation until the end of the 12-month period. If they are admitted to another facility from the hospital, they are eligible for another 14-day bed reservation in the new facility once residency is established. If the resident is readmitted to the original facility (where they have priority readmission) after establishing residency at a second facility, they are eligible for another 14-day bed reservation period once residency is re-established in the original facility.

4. In order to qualify for bed hold, must the recipient be on Medicaid for one full day or for 30 days?

A recipient must be a resident of a facility for 30 days since the date of initial admission before reimbursement is available for a bed reservation. Days do not have to be consecutive but must be within the facility to be considered a valid period of residency. (Note: Respite days do not apply to residency.) Medicaid must be the primary payor for one of those days.

If a bed is being reserved with private pay funds, can the facility charge the private pay rate or must it charge the Medicaid daily rate?

The facility can charge the private pay rate for privately held beds; however, this rate must be reflected in the resident's admission agreement. This applies to beds held for residents who pay privately (non-Medicaid) or for Medicaid recipients whose stay has exceeded the 14-day bed hold limit.

5. If a resident reaches the 14-day bed hold limit and the bed is not billable, is the resident who is hospitalized or on therapeutic leave excluded from the 95% occupancy rule?

Yes, an unpaid bed counts as a vacancy.

If we discharge a resident because of the bed hold limit and the bed is now vacant, do we include this discharge on the RHCF-4 reporting for length of stay?

The resident is not considered "discharged." The bed is released for purposes of reimbursement, and is considered to be vacant and open for a new admission. The facility should only report actual bed hold days billed on the RHCF-4 cost report.

6. If a resident was hospitalized and on bed hold prior to July 19, 2010 and returned to the facility after July 19, 2010 (i.e., hospital admission from July 15th to August 1st), do the new bed hold rules apply to the resident as of August 1, 2010, thus giving him 14 paid bed hold days from August 1, 2010 to July 31, 2011?  Or, does his hospitalization from July 19, 2010 to August 1, 2010 use 13 of the 14 reimbursable days, leaving the resident with one more bed hold day that is reimbursable until July 18, 2011?

In the scenario that is described, the resident used 13 of his 14 bed hold days from July 19, 2010 to July 31, 2010 and would have one more day until July 18, 2011.

7. If a resident has used his/her 14 days and no longer has a bed hold, does the SNF have to hold the bed?

The NH must hold the bed only if the resident or his/her representative chooses to pay privately for the bed; otherwise, it is released for a new admission.

Many of our residents go back and forth to the hospital often, and may lose their bed hold days quickly. Is the nursing home expected to continue to hold the bed for a resident each time they go out on leave?

No, the nursing home is not expected to hold the bed, but residents who have used the 14 day bed hold are eligible for priority readmission pursuant to the existing regulations under 10 NYCRR 415.3(h)(4)(iii). A nursing home shall establish and follow a written policy under which a resident whose hospitalization or therapeutic leave exceeds the bed hold days 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.

There are times when a number of residents are in the hospital or on therapeutic leave. With the limitation on the total number of days, is it correct that the census may drop below the 5 percent level as residents lose their bed holds?

This is correct. The daily census is affected when residents lose their bed holds due to hospitalizations and therapeutic leaves that exceed the 14-day and 10-day bed hold periods, respectively.

8. If a resident is a new admission on July 10, 2010, does residency begin on August 10, 2010 or does the 30-day residency period begin on July 19, 2010 with residency established on August 19, 2010?

A resident who is admitted on July 10th will fulfill the residency requirement as of August 8th, which the 30th day of residency.

9. NYCRR Title 18, Section 505.9 (d)(6)(i) requires nursing homes to give verbal and written notification of bed hold status to hospitals. It states that if the hospitalization is expected to be more than 15 days, the facility is to discharge the resident immediately. If less than 15 days, the nursing home may retain the resident on a bed hold. Is this policy and the requirement to notify hospitals now null and void, or has the regulation been amended with different time frames?

Title 18 has not been revised to reflect the new statute at this time. The facility should reserve the bed if the resident is expected to return within 15 days and the resident has available bed hold days. Payment for bed reservation will be limited to 14 days in a 12-month period.

10. The family of one of our residents called the county and was told that extensions could be given to the 14 day period. We have not seen that extensions are available and if they are, do they just apply to one hospitalization or can it be requested if there is another hospital stay. The family was also told that this did not apply to long-term residents but only short-term. Has there been proper communication to the counties on this issue?

The new statute does not permit any extensions and applies to all nursing home residents, both short-term and long-term. Bed holds can apply to more than one hospitalization provided the initial hospitalization did not exceed the 14 day limit. Counties are being notified of the new statute in accordance with current protocol.

11. Discrepancies were noted in regulations cited in paragraph #3 of the August 13, 2010 DAL, question #1 in the attachment to that DAL, and question #7 of the attachment to the July 19, 2010 DAL. The regulation pertains to resident transfer, discharge and readmission rights. Clarification of the regulation citation is requested.

The correct regulation citation in paragraph #3 of the August 13, 2010 DAL is 415.3(h). The correct regulation citation for questions #7 and #1 of the July 19, 2010 and August 13, 2010 DALs, respectively, is 415.3(h)(4)(iv). New regulations are being drafted and will be subject to the SAPA requirements

12. Responses to questions #16, #20, #21 and #22 of the August 13, 2010 address the 95% reduction for bed hold claims. Please clarify.

The responses to these questions should have stated, "the 5% reduction for bed hold claims."

13. According to the DAL dated August 13, 2010, one of the exclusions to the new bed hold reimbursement limitations is residents on hospice.

  • What regulations apply in regard to bed hold if a resident on hospice is sent to the hospital?
  • Does this apply only to residents in certified hospice beds (i.e. hospice facility)?
  • What about a resident in a skilled SNF bed who is receiving hospice services (via contract with the hospice)?

As indicated in 18 NYCRR 505.9(d)(3)(vii), a hospice may receive Medicaid payments for reserved bed days for recipients who reside in an RHCF and are in receipt of hospice services. The 2010 bed reservation statute affects neither these payments nor other regulatory provisions with respect to these recipients.

14. Are unoccupied beds counted in the daily census?

Any bed that has a payor (including both Medicaid reserved and private pay) is included in the daily census. Beds without a payor are considered vacant and should not be counted in the census.

15. Is the 95% Medicaid reimbursement rate for reserved bed days calculated day by day or on the total of the days being billed for that period? How is the 95% calculation done? Is it rounded to nearest cent? Rounded up or rounded down?

The payment is calculated as follows: Base Amount = Sum of (Rate Amount * Number of Days for each rate period)

If the Category of Service = 0286 or 0381, Client age >= 21 years old, and Revenue Code 0183 or 0185 is present on the claim, the Base Amount is reduced by 5%. This reduction is effective April 1, 2010.

The rounding is done in accordance with common accounting practice rounding rules. If the fraction is less than .005 it is dropped, if equal to or greater than .005 it is rounded up to the next cent.

16. What is the responsibility of the facility to administer discharge notices with appeal rights for residents who: Do not meet the criteria for bed hold for hospitalization and do not wish to pay for private bed hold?

Having no bed hold, or an exhausted bed hold, are not acceptable regulatory reasons for discharge. In order to discharge a resident, the resident must fall into one of the categories specified in 10 NYCRR 415.3(h), which addresses Transfer and Discharge rights:

  • 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.

Have exhausted their fourteen day or ten day bed hold for hospitalization or therapeutic leave, respectively, and choose not to pay for private bed hold?

If the resident wishes to return to the facility once the temporary hospitalization/therapeutic leave have ended, he/she would be eligible for the next available semi-private bed. The resident would not be considered discharged from the facility until the facility discharges him/her in accordance with 10 NYCRR 415.3(h) (see the previous bullet) or the resident and or designated representative voluntarily elects not to return.

Reside in a facility whose policy it is to discharge residents not on bed hold.

The facility's discharge policy must be compliant with 10 NYCRR 415.3(h) above. A facility shall not discharge a resident solely because there is no bed hold.

17. Does a Medicaid pending resident have any rights to return to the first available bed when their bed hold days are exhausted?

The new bed reservation statute applies only to established Medicaid recipients. A RHCF has the responsibility to offer all residents the next available semi-private bed (priority readmission), regardless of payor source.

18. In cases where a RHCF provider does not receive hospital documentation, will it be sufficient for the RHCF to maintain documentation of the hospital conversations regarding expected date of discharge?

Yes, maintaining this documentation is sufficient.

19. Is there a grace period for notification of transfer and discharge rights and bed hold policy, especially for those individuals that were temporarily hospitalized or on non-hospitalization leave of absence the day the new reserved bed day policy took effect?

In accordance with the new law, there is no grace period. The 12-month period for those Medicaid recipients who had established residency began on 7/19/10.

20. Does a resident that is only admitted for observation count as a hospitalization for the purpose of a bed hold?

All bed reservation requirements need to be met in order for a facility to bill for a reserved bed day. A facility can submit for a bed-hold when the resident is admitted to the hospital for an inpatient-stay.

21. On the website under frequently asked questions, the last question and answer is as follows: "Are there any relevant Dear Administrator Letters (DALs) on the Department's website?"

The answer is yes, and several links are provided. When you click on one of these three links you get an error message. Where else can these documents be found?

These links are functioning properly on the Department's website. These documents can also be found on the Health Commerce System (HCS), formerly known as the HPN.

22. Paragraph three of Dear Administrator Letter (DAL/DRS: 10-08 [dated July 19, 2010]) states that the facility must hold the bed for the resident's return for the entire length of the hospitalization and also if the non-hospital leave of absence is in the plan of care. Does that mean that the bed is held but that the facility is not paid by Medicaid and the resident is still guaranteed a bed at the facility upon return?

For temporary hospitalizations, the facility is not expected to hold the bed the entire length of the hospitalization, but if a resident exhausts their 14-day bed hold, the resident must be given priority readmission. For non-hospital (therapeutic) leaves of absence, if the resident's care plan documents the need for more than 10 days in a 12-month period, the facility may allow additional visits, but will only be reimbursed for 10 therapeutic leave days per year.

23. I work for a hospital in Massachusetts and we have patients with NY Medicaid. If they come to us from a Skilled Nursing Facility how long do you hold the bed, 15 days in a one year period or 15 days each time they come in the hospital? Please clarify for me.

Chapter 109 of the Laws of 2010, enacted on June 8, 2010, changed reserved bed day reimbursement to residential health care facilities (RHCFs) for Medicaid eligible individuals aged twenty-one and older. Effective July 19, 2010, the Department will reimburse a RHCF to reserve the bed for a Medicaid recipient aged twenty-one or over, for 14 days in a 12-month period for temporary hospitalizations.

24. Can someone please clarify the vacancy percentage calculation for a bed hold qualification? For instance, if my SNF has 160 but 20 are vent beds all on one unit then I understand that the vacancy on the vent unit can't be more than 5% of the 20 beds. Is this correct? Also, if this is correct, how do we round? For instance, if my vent beds are 26 then 5% of 26 is 1.30. Does this equal 1 bed or 2 for the vacancy percentage?

This is incorrect. The steps for computing a vacancy rate are as follows:

Only beds occupied by individuals meeting the admission criteria for and admitted to the unit may be counted as occupied toward the census of that unit.

For example, a facility with a 201 bed geriatric unit would:

  • Count the total number of unoccupied beds in the unit at the time the census is taken (e.g., 18 beds).
  • Subtract from the unoccupied bed count (18 beds) those vacant beds for clients temporarily absent from the facility in the previous 24 hours who have not exhausted their allowable/billable reserved bed days in the current 12 month period. (e.g., 2 beds, thus 18- 2= a subtotal of 16 beds).
  • Subtract from this subtotal (16 beds) those vacant beds that are already in bed-hold status from the previous day's census, and that remain eligible for bed-hold status at the time of the current census (e.g., 6 beds, subtotaling 10 beds).
  • Divide the number derived from the three steps above (10 beds) by the licensed capacity of that unit (201 beds) to determine the vacancy rate of the unit (.04975 or 4.975%).

25. Please clarify response to question 9 which is part of the Q&A of DAL of 8/13.

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."

I originally understood that any given facility is allowed a maximum of 14 bed hold hospitalization days a year. The answer provided above indicates that the 12 month clock restarts if resident is readmitted and satisfies the 30 day residency implying that facility may bill for another set of 14 bed hold days. I'm totally confused since this is not a total of 14 days a year. Please clarify.

Residents who are hospitalized and readmitted to the same facility based on priority readmission are not eligible for another 14-day bed reservation until the end of the 12-month period. If they are admitted to another facility from the hospital, they are eligible for another 14-day bed reservation in the new facility once residency is established. If the resident is readmitted to the original facility (where they have priority readmission) after establishing residency at a second facility, they are eligible for another 14-day bed reservation period once residency is re-established in the original facility.