La. Admin. Code tit. 50 § II-10109

Current through Register Vol. 50, No. 11, November 20, 2024

Section II-10109 - Withdrawal from the Medicaid Program

A. A facility may involuntarily or voluntarily lose its participating status in the Medicaid Program. When a facility loses its participating status in the Medicaid Program, a minimum of ten percent of the final vendor payment to the facility is withheld pending the fulfillment of the following requirements:

1. completion of a limited scope audit of the residents' funds account and the disposition requirements for nurse aide training funds with findings and any recommendations of a qualified accountant of the facility's choice submitted to the BHSF Institutional Reimbursement Section. The facility has 60 days to submit the audit findings to the BHSF Institutional Reimbursement Section once the section notifies the facility that a limited scope audit is required. Failure of the facility to comply is considered a class E violation and will result in fines as outlined in the Subchapter L entitled sanctions;

2. the facility's compliance with the recommendations of the limited scope audit and the disposition requirements for nurse aide training funds;

3. submittal of an acceptable final cost report by the facility to BHSF Program Operations Section.

B. Once these requirements are met, the portion of the payment withheld shall be released by BHSF Program Operations.

NOTE: If a SN-ID or SN-TDC withdraws from the Medicaid Program, the 10 percent will not be released until the above requirements are met and after cost settlement.

C. In situations where a facility either voluntarily or involuntarily discontinues its operations or participation in the Medicaid Program, residents, residents legal representative or sponsor, and other appropriate agencies or individuals shall be notified as far in advance of the effective date as possible to ensure an orderly transfer and continuity of care. The owner or administrator shall submit written notice of withdrawal to BHSF/HSS at least 30 days in advance of a voluntary withdrawal.

D. If the facility is closing its operations, plans shall be made for transfer. If the facility is voluntarily or involuntarily withdrawing from Medicaid Program participation, the resident has the option of remaining in the facility on a private-pay basis.

E. Payment Limitation

1. Payments may continue for residents up to 30 days following the effective date of the facility's certification of non-compliance.

2. The payment limitation also applies to Medicaid applicants and recipients admitted prior to the certification of non-compliance notice.

3. Payment is continued only if the facility totally cooperates in the orderly transfer of applicants/recipients to other Medicaid facilities or other placements of their choice.

NOTE: The facility shall not admit new Medicaid applicants/recipients after receiving the certification of non-compliance notice. There shall be no payment approved for such an admittance.

4. DHH may cancel the provider agreement if and when it is determined that the facility is in material breach of contract.

F. Facility Certification of Non-Compliance

1. When the DHH Bureau of Health Services Financing, Health Standards Section determines that a facility no longer meets state and federal Medicaid certification requirements, action is taken. Usually an advance certification of non-compliance date is set unless residents are in immediate danger.

2. Certification of Non-Compliance Notice

a. On the date the facility is notified of its certification of non-compliance, DHH shall immediately begin notifying residents, residents legal representative or sponsor, and other appropriate agencies or individuals of the action and of the services available to ensure an orderly transfer and continuity of care.

b. The process of certification of non-compliance requires concentrated and prompt coordination among the following groups:

i. the BHSF Health Standards regional office;

ii. the parish office of DHH BHSF, Medicaid Program;

iii. the facility; and

iv. other offices as designated by DHH.

c. This coordination effort shall have the following objectives:

i. protection of residents;

ii. assistance in finding the most appropriate placements when requested by residents and/or responsible parties; and

iii. timely termination of vendor payment upon the resident's discharge from the facility.

NOTE: The facility still retains its usual responsibility during the transfer/discharge process to notify the parish office of DHH/BHSF Medicaid Program promptly of all changes in the resident's status.

3. Transfer Team. DHH shall designate certain staff members as a transfer team when a mass transfer is necessary. Their responsibilities shall include supervising transfer activities in the event of a proposed facility certification of non-compliance with Medicaid participation. The following procedures shall be taken by or under the supervision of this team.

a. Supervision and Assistance. When payments are continued for up to 30 days following certification of non-compliance, the transfer team shall take the following actions:

i. supervise the facility certification of non-compliance and transfer of its Medicaid residents;

ii. determine the last date for which vendor payment for resident care can be made; and

iii. assist in making the most appropriate arrangements for the residents, providing the team members' names as contact persons if such help is needed.

b. Effecting the Transfer. To ensure an orderly transfer or discharge, the transfer team shall also be responsible for performing the following tasks:

i. they shall meet with appropriate facility administrative staff and other personnel as soon as possible after termination of a provider agreement to discuss the transfer planning process;

ii. they shall identify any potential problems;

iii. they shall monitor the facility's compliance with transfer procedures;

iv. they shall resolve disputes in the resident's best interest; and

v. they shall ensure that the facility takes an active role in the transfer planning.

vi. the local ombudsman and advocacy agencies shall be notified.

Note: The facility's failure to comply with the transfer team's requests may result in denial of reimbursement during the extension period.

c. Provisions for Resident Services During Transfer or Discharge. DHH has the following responsibilities:

i. to provide social services necessary in the transfer or discharge plan or otherwise necessary to ensure an orderly transfer or discharge in accordance with the State Plan of the Medicaid Program; and

ii. to obtain other services available under Medicaid.

d. Parish DHH/BHSF Medicaid Program Responsibilities: Applicant/Recipient Status Listing. The parish office of DHH/BHSF Medicaid Program shall maintain a listing of each applicant/recipient's status as authorization forms are submitted regarding transfer or discharge. At the conclusion of the 30 day period referred to above, the transfer team shall submit a report to the office of DHH/BHSF Medicaid Program, outlining arrangements made for all Medicaid applicants/recipients.

e. Resident Rights. Nothing in the transfer or discharge plan shall interfere with the existing bill of rights.

G. Recertification of an Involuntary Withdrawal. After involuntary certification of non-compliance, a facility cannot participate as a provider of Medicaid services unless the following conditions are met:

1. the reasons for the certification of non-compliance of the contract no longer exist;

2. reasonable assurance exists that the factors causing the certification of non-compliance will not recur;

3. the facility demonstrates compliance with the required standards for a 60 day period prior to reinstatement in a participating status; and

4. the initial survey verifies that residents are receiving proper care and services;

5. certification requirements for swing bed hospitals. Small rural hospitals may certified to provide Medicaid nursing facility services if all of the following conditions are met:

a. the hospital has a valid agreement as a title XVIII (Medicare) provider of swing bed services;

b. the hospital has fifty hospital beds or fewer, excluding beds for newborns and beds in intensive care type in residents units;

c. the hospital is located in an area not designated as "urban" in the most recent census;

d. a facility need review approval has been granted;

e. the hospital is not operating under a waiver of the hospital requirements for 24 hour nursing services;

f. the hospital has a valid title XIX (Medicaid) agreement as a provider of acute care hospital services;

g. the hospital has not had a swing bed title XVIII (Medicare) or Title XIX (Medicaid) approval terminated within two years previous to application;

h. a provider of swing bed services shall comply with conditions for title XIX (Medicaid) participation as both acute care hospital and Medicaid nursing facility; however, a lack of compliance with nursing facility requirements does not affect participation as a provider of acute care hospital services;

i. hospitals seeking to enroll as swing bed facilities on or after July 9, 1987 shall also meet the following criteria:

i. possess a current nursing home license;

ii. be administered by a licensed Nursing Home Administrator;

iii. meet the need and resource goals as established in facility need review regulations; and

iv. list enrollment to ten percent of bed capacity.

La. Admin. Code tit. 50, § II-10109

Promulgated by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR 22:34 (January 1996).

AUTHORITY NOTE: Promulgated in accordance with R.S. 46:153.