Limitations on Allowable Nursing Facility Costs to Reserve a Bed for Absences Due to Hospital Admission

PURPOSE: This rule outlines the coverage of nursing facility costs to reserve a bed in a nursing facility during an absence from the facility due to a hospital admission of three (3) days or less and the limitations related to that coverage. (1) Payment to a nursing facility (NF) for hospital leave days is authorized for days in which a Medicaid participant is absent from the NF due to admission to a hospital for services which cannot be performed on an outpatient basis, subject to the following: (A) The nursing facility in which the Medicaid resident resides is licensed under Chapter 198, RSMo; (B) The NF is in compliance with all federal and state certification standards; (C) The occupancy rate of the NF is at or above ninety-seven percent (97.00%), rounded to four (4) decimal places (i.e., 0.9700 or 97.00%), of Medicaid certified beds for the quarter prior to the quarter during which hospital leave is taken. The occupancy rate is based on the data from the Certificate of Need (CON) Quarterly Survey from the Department of Health and Senior Services. The quarters referenced herein are calendar year quarters (i.e., January – March, April – June, July – September, and October – December); (D) The Medicaid participant is admitted to a hospital for a medical condition, which cannot be treated on an outpatient basis, with a total stay of three (3) days or less; and (E) The hospital provides a discharge plan for the participant which includes returning to the facility requesting the hospital leave days. (2) The payment for hospital leave days shall only be provided for qualified hospital stays of three (3) days or less. A qualified hospital stay is one in which the medical condition cannot be treated on an outpatient basis. (3) The hospital leave days billed by the nursing facility shall be held in suspense until the nursing home bill, hospital bill, and quarterly census have been received by the MO HealthNet Division so appropriate payment can be determined. (4) Payment for authorized hospital leave days shall be at the per-diem rate for the respective provider. (5) For each day that Medicaid reimburses a nursing facility, pursuant to this subsection, the Medicaid participant shall be ineligible for reimbursement to nursing facilities for two otherwise available temporary leave of absence days as described in 13 CSR 70-10.015(5)(D). The total hospital leave days and temporary leave of absence days shall not exceed the limits for the periods defined in 13 CSR 70-10.015(5)(D). AUTHORITY: sections 208.153, 208.159, 208.201, and 660.017, RSMo 2016.* Emergency rule filed Dec. 17, 1993, effective Dec. 27, 1993, expired April 25, 1994. Emergency rule filed April 15, 1994, effective May 1, 1994, expired Aug. 28, 1994. Original rule filed Nov. 2, 1993, effective June 6, 1994. Amended: Filed Aug. 28, 2018, effective April 30, 2019. *Original authority: 208.153, RSMo 1967, amended 1973, 1989, 1990, 1991; 208.159, RSMo 1979; 208.201, RSMo 1987; and 660.017, RSMo 1993, amended 1995.