Ala. Admin. Code r. 560-X-7-.30

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

Section 560-X-7-.30 - Post-Hospital Extended Care Services

(1) Inpatient hospital services rendered at an inappropriate level of care (lower than acute) are considered posthospital extended care services. The patient must have received a minimum of three consecutive days of acute care services in the hospital requesting Post-Hospital Extended Care (PEC) reimbursement. Infrafacility transfers will not be authorized for reimbursement as PEC services. These services include care ordinarily provided by a nursing facility. (Refer to Chapter 10.) Such medically necessary services include, but are not limited to:

(a) Nursing care provided by or under the supervision of a registered nurse on a 24hour basis;

(b) Bed and board in a semiprivate room. Private accommodations may be utilized if the patient's condition requires that he/she be isolated, the facility has no ward or semiprivate rooms, or all ward or semiprivate rooms were full at the time of admission and remain so during the recipient's stay;

(c) Medically necessary overthecounter (nonlegend) drug products ordered by physician. Generic brands are required unless brand name is specified in writing by the attending physician;

(d) Personal services; and

(e) Nursing and treatment These include, but are not limited to, needles, syringes, catheters, catheter trays, drainage bags, indwelling catheters, enema bags, normal dressing, special dressings (such as ABD pads and pressure dressings), intravenous administration sets, and normal intravenous fluids (such as glucose, D5W, D10W, and normal saline);

(f) Services ordinarily furnished to an inpatient of a hospital.

(2) In order for such services to be reimbursed, the hospital must submit a written request to Medicaid to receive a provider number that will allow them to use up to ten beds for these services for hospitals with up to 100 beds, with an additional ten beds per each additional 100 beds. Prior to the hospital admitting a patient to one of these beds, the hospital must first determine that there is no nursing facility bed available within a reasonable proximity, and the recipient must require on a regular basis two of the following medically necessary services:

(a) Administration of a potent and dangerous injectable medication and intravenous medications and solutions on a daily basis;

(b) Restorative nursing procedures (such as gait training and bowel and bladder training) in the case of residents who are determined to have restorative potential and can benefit from the training on a daily basis;

(c) Nasopharyngeal aspiration required for the maintenance of a clear airway;

(d) Maintenance of tracheotomy, gastrostomy, colostomy, ileostomy, or other tubes indwelling in body cavities as an adjunct to active treatment for rehabilitation of disease for which the stoma was created;

(e) Administration of tube feedings by nasogastric tube;

(f) Care of extensive decubitus ulcers or other widespread skin disorders;

(g) Observation of unstable medical conditions required on a regular and continuing basis that can only be provided by or under the direction of a registered nurse;

(h) Use of oxygen on a regular or continuing basis;

(i) Application of dressing involving prescription medications and aseptic techniques and/or changing of dressing in noninfected, post operative, or chronic conditions; or

(j) Receive routine medical treatment as a comatose patient.

(3) To establish medical necessity, an application packet must be furnished to the Medicaid Admissions Program within 60 days from the date Medicaid coverage is requested. The 60 days will be calculated from the date the application is received and date stamped in the Admissions Program. All applications with a date greater than 60 days old will be assigned an effective date that is 60 days prior to the Admissions Program date stamp. No payment will be made for the days prior to the assigned Admissions Program effective date. The facility will be informed in writing of the assigned effective date. The application packet will consist of:

(a) A fully completed Medicaid Status Notification Form XIXLTC4 including all documentation certified by the applicant's attending physician to

(b) Documentation certifying the patient has received inpatient acute care services for no less than three consecutive days during the current hospitalization in the requesting hospital prior to the commencement of postextended care services. These days must have met the Medicaid Agency's approved acute care criteria; and

(c) Documentation certifying contact was made with each nursing facility within a reasonable proximity to determine bed nonavailability prior to or on the date coverage is sought, and every 15 days thereafter.

(4) In order to continue (Post-Hospital Extended Care) eligibility, recertification must be made every 30 days. Nursing facility bed nonavailability must be forwarded along with request for recertification.

(5) Reimbursement for (posthospital extended care) services will be made on a per diem basis at the average unweighted per diem rate paid by Medicaid to nursing facilities for routine nursing facility services furnished during the previous fiscal year ended June 30. There shall be no separate Chapter 560-X-7 Medicaid year end cost settlement. Refer to Chapter 22 of the Alabama Administrative Code for details on rate computation.

(6) A provider must accept as payment in full the amount paid by Medicaid plus any patient liability amount to be paid by the recipient and further agrees to make no additional charge or charges for covered services.

(7) Any day a patient receives such posthospital extended care services will be considered an acute care inpatient hospital day. These beds will not be considered nursing facility beds.

(8) These services are not subject to inpatient hospital benefit limitations. At this level of care, posthospital extended care days are unlimited if a nursing home bed is not located as described in paragraphs (2) and (3)(d) above.

Author: Beverly Rotton, Project Development/Policy Unit, Long Term Care Division

Ala. Admin. Code r. 560-X-7-.30

New Rule: Filed June 7, 1994; Effective July 13, 1994. Amended: Filed April 5, 1995; effective May 10, 1995. Amended: Filed March 7, 1997; effective April 11, 1997. Amended: Filed October 6, 1999; effective November 10, 1999.

Statutory Authority: Social Security Act, Title XIX; State Plan; and 42 C.F.R. §447.253(b).