Denial of Payments in Lieu of Termination of ICFs/IID

3006 - Denial of Payments in Lieu of Termination of ICFs/IID (Rev. 92, Issued, 11-22-13, Effective: 11-22-13, Implementation: 11-22-13) 3006A - Authority to Deny Payment for Any New Admissions for ICFs/IID (Rev.92, Issued, 11-22-13, Effective: 11-22-13, Implementation: 11-22-13) Section 1902(i) of the Act and 42 CFR 442.118 provide the SMA with an alternative to terminating ICFs/IID that fail to meet program requirements. This sanction is the one- time denial of payment for new admissions for a period of up to 11 months after the month it was imposed, if the facility’s deficiencies do not present an immediate jeopardy to residents’ health and safety. A decision is made at the end of 11 months whether to continue participation. However, the 11-month period can be shortened if circumstances change and there is immediate jeopardy to health and safety before 11 months have passed. Alternatively, the State might rescind the denial of payments in fewer than 11 months if full compliance is achieved or if the ICF/IID has made significant, good-faith efforts and progress in achieving compliance. 3006B - Criteria for Imposing Denial of Payments for New Admissions (Rev. 1, 05-21-04) The SMA retains the right to establish its own criteria for imposing this sanction. However, the SMA may not use this sanction if the facility’s deficiencies pose immediate jeopardy to the health and safety of its clients. 3006C - Agency Procedures (Rev. 92, Issued, 11-22-13, Effective: 11-22-13, Implementation: 11-22-13) Before denying payment for new admissions, the SMA must comply with the following requirements: • Provide the ICF/IID up to 60 calendar days to correct the cited deficiencies and comply with the CoP. • If at the end of the specified period the ICF/IID has not achieved compliance, give the facility notice of intent to deny admissions and the opportunity for an informal hearing. • If the ICF/IID requests a hearing and the decision of the hearing is to deny payment, the SMA must provide the facility and the public, at least 15 calendar days before the effective date of the sanction, a notice that includes the effective date of the sanction and the reasons for the denial of payment. 3006D - Effect of Sanction on Status of Clients Admitted, Discharged, or on Temporary Leave and Readmitted Before or After Effective Date of Denial of Payment (Rev. 1, 05-21-04) The client’s status on the effective date of the denial of payment is the controlling factor in determining whether readmitted clients are subject to the denial of payment. Guidelines are as follows: • Clients who were admitted and discharged before the effective date of the denial of payment are considered new admissions if they are readmitted on or after the effective date. Therefore, they are subject to the denial of payment; • Clients admitted on or after the effective date of the denial of payment are considered new admissions. If readmitted after being discharged, they continue to be considered new admissions, and are subject to the denial of payment; • Clients admitted before and discharged on or after the effective date of the denial of payment are considered new admissions if subsequently readmitted. Therefore, they are subject to the denial of payment; • Clients admitted before the effective date of the denial of payment who take temporary leave before, on, or after the effective date of the denial of payment are not considered new admissions upon return and therefore, are not subject to the denial of payment; and • Clients admitted on or after the effective date of the denial of payment who take temporary leave are not considered new admissions, but continue to be subject to the denial of payment. NOTE: The term “temporary leave” refers to clients who leave temporarily for any reason. If clients were not subject to a denial of payment when they went on temporary leave, the term indicates that upon return they are not considered new admissions for the purposes of the denial of payment. Therefore, the term “temporary leave” is used to justify a resumption of any interrupted payment upon re-entry into the facility. The term “leave of absence” is defined as any situation where the client is absent, but not discharged, for reasons other than admission to a hospital, SNF or NF, or distinct part of a SNF or NF. The term “leave of absence” is used for the purpose of preventing duplicate payments during an absence by assuring that the absence is not due to a temporary alternate inpatient arrangement. If the client is not on a leave of absence but is actually temporarily in an alternate inpatient situation, any ongoing payment to the facility will be interrupted as mentioned above. The client who is not subject to the denial of payment sanction and who goes on temporary leave, whether there is a leave of absence, will not be considered a new admission for the purposes of the denial of payment sanction, upon his/her return to the facility. Any interrupted payment will be resumed. In either situation, it is expected that the client will return to the facility following leave. 3006F - Duration of Denial of Payment and Subsequent Termination of an ICF/IID (Rev. 92, Issued, 11-22-13, Effective: 11-22-13, Implementation: 11-22-13) The denial of payment for new admissions will continue for eleven months unless, before the end of that period, the SMA finds that the ICF/IID has corrected the deficiencies or is making a good faith effort to achieve compliance with the CoPs or the deficiencies are such that it is necessary to terminate the facility. The SMA must terminate the facility’s provider agreement: • Upon finding that the ICF/IID has been unable to achieve compliance with the CoPs during the 11-month period that payments were denied for new admissions; and • Termination is effective the day following the last day of the denial of payment period.