Ala. Admin. Code r. 560-X-10-.05

Current through Register Vol. 43, No. 1, October 31, 2024

Section 560-X-10-.05 - Reservation of Beds

(1) Payment for Reservation of Beds in Long Term Care Facilities.

(a) Neither Medicaid patients, nor their families, nor their sponsor, may be charged for reservation of a bed for the first four days of any period during which a Medicaid patient is temporarily absent due to admission to a hospital. Prior to discharge of the patient to the hospital, the patient, the family of the patient or the sponsor of the patient is responsible for making arrangements with the nursing home for the reservation of a bed and any costs associated with reserving a bed for the patient beyond the covered four day hospital stay reservation period. The covered four day hospital stay reservation policy does not apply to:

1. Medicaid-eligible patients who are discharged to a hospital while their nursing home stay is being paid by Medicare or another payment source other than Medicaid;

2. Any non-Medicaid patients;

3. A patient who has applied for Medicaid but has not yet been approved; provided that if such a patient is later retroactively approved for Medicaid and the approval period includes some or all of the hospital stay, then the nursing home shall refund that portion of the bed hold reservation charge it actually received from the patient, family of the patient or sponsor of the patient for the period that would have been within the four covered days policy; or

4. Medicaid patients who have received a notice of discharge for non-payment of service.

(2) Upon entering the hospital or the resident being placed on therapeutic leave, a nursing facility must provide to the resident and a family member or legal representative written notice which specifies the duration of the bed-hold policy. The bed-hold policy specifies when a resident is permitted to return and resume residence in the nursing facility.

(3) When a nursing facility is contacted by the hospital notifying them that the resident is ready for release, within the four day bed-hold period, the nursing facility must allow the resident to return to their facility before the bed-hold period expires provided the resident is an appropriate placement for nursing facility care and the nursing facility provides the type of services that meets the needs of the resident. The nursing facility must have documented verifiable evidence in the resident's medical record to indicate that there has been a significant change in the resident's condition, either prior to or during the hospital stay, making re-admission to the nursing facility inappropriate because the nursing facility can no longer meet the needs of the resident. When such a significant change in a resident's condition occurs prior to discharge to the hospital, the nursing facility should use reasonable efforts to begin to arrange for appropriate placement for the resident prior to transferring the resident to the hospital. If there is documented evidence in the medical record that the nursing facility is refusing to re-admit a resident without valid cause as determined by the Alabama Medicaid Agency, the Alabama Medicaid Agency shall notify the Division of Health Care Facilities, Alabama Department of Public Health, for appropriate enforcement action. If enforcement action ensues and results in_program termination, any loss of nursing facility payment during the time that the nursing facility contract is terminated will not be considered a reimbursable Medicaid cost.

(4) A nursing facility or ICF/IID must establish and follow a written policy under which a resident who has been hospitalized or who exceeds therapeutic leave or bed-hold policy is readmitted to the facility immediately upon the first available bed in a semi-private room if the resident requires the services provided by the facility.

(5) Four day bed-hold. If a nursing facility refuses to take a resident back who has been released from the hospital during the four day bed-hold period, provided the resident is an appropriate placement for nursing facility care and the nursing facility provides the type of services capable of meeting the resident's needs, Medicaid may terminate the facility's provider agreement for failing to adhere to the rules set forth in the federal and state bed-hold policy until an acceptable plan of correction is received from the nursing facility. In situations where the facility has decided to discharge the resident while the resident is still hospitalized, the facility must send a notice of discharge to the resident and the resident representative, and must also send a copy of the discharge notice to a representative of the Office of the State LTC Ombudsman and Medicaid. If the Alabama Medicaid Agency determines that the nursing facility has failed to follow the rules set forth in the federal and state bed-hold policies, the Alabama Medicaid Agency shall notify the Division of Health Care Facilities, Alabama Department of Public Health, for appropriate enforcement action. If enforcement action ensues and results in program termination, any loss of nursing facility payment during the time that the nursing facility contract is terminated will not be considered a reimbursable Medicaid cost.

Ala. Admin. Code r. 560-X-10-.05

Rule effective October 1, 1982. Emergency rule effective October 1, 1990. Amended effective February 13, 1991. Amended: Filed September 7, 1999; effective October 12, 1999. Amended: Filed July 7, 2000; effective August 11, 2000. Amended: Filed February 8, 2002; effective March 15, 2002. Amended: Filed August 11, 2003; effective September 11, 2003. Amended: Filed May 14, 2008; Re-Filed June 12, 2008 (per suggested amendments by JCARR); effective June 18, 2008.

Amended by Alabama Administrative Monthly Volume XXXV, Issue No. 04, January 31, 2017, eff. 2/25/2017.

Amended by Alabama Administrative Monthly Volume XXXVI, Issue No. 12, September 28, 2018, eff. 10/26/2018.

Author: Robin Arrington, Associate Director, LTC Program Recipient/Services Unit

Statutory Authority: State Plan; Title XIX, Social Security Act; 42 C.F.R. §§ 401, et seq. ; 483.12.