210 R.I. Code R. 210-RICR-50-05-1.5

Current through December 3, 2024

Section 210-RICR-50-05-1.5 - Medicaid LTSS in Nursing Facilities

A. In general, licensed nursing facilities provide a mix of the following services:

1. Skilled nursing -- Intermittent or continuous skilled nursing or medical care and related services to address a clinical condition and/or functional limitation;

2. Subacute care -- Rehabilitative services needed due to injury, disability, or illness;

3. Long term services and supports -- Health-related services and supports (above the level of room and board) needed regularly due to a clinical or functional disability. Previously referred to as "custodial care";

4. Hospice care - An array of services furnished to terminally ill beneficiaries including, nursing, medical social services, physician services, counseling services for the beneficiary, family members, and/or other care givers. When provided in a NF, hospice is an elective service in which the beneficiary waives access to treatments to cure the terminal illness in favor of palliative care. This election may be revoked at any time.

B. There is no exhaustive list of required Medicaid services in the NF benefit. A Medicaid participating NF is required to provide, or arrange for, nursing or related services and specialized rehabilitative services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident as established in a beneficiary's individualized plan of care.

C. In accordance with the Rhode Island Medicaid State Plan and federal regulations:

1. Minimum services -- A NF must provide, and residents may not be charged for, at least:

a. Nursing and related services;

b. Specialized rehabilitative services including any required for residents who have a mental illness or intellectual disability, that are not provided or arranged for by the State, as specified in the PASSR evaluation set forth in Subchapter 00 Part 5 of this Chapter;

c. Medically related social services;

d. Pharmaceutical services including acquiring, receiving, dispensing, and administering of drugs and biologicals;

e. Dietary services individualized to the needs of each resident;

f. Professionally directed program of activities to meet the interests and needs for well-being of each resident;

g. Emergency dental services and routine dental services covered under the State Plan;

h. Room and bed maintenance services; and

i. Routine personal hygiene items and services.

2. The NF is not required to but may provide and charge residents for:

a. Private rooms, unless medically needed;

b. Specially prepared food, beyond that generally prepared by the facility;

c. Access to and use of social and electronic media, including the internet, and/or a telephone, television, or radio;

d. Personal comfort items including tobacco products and confections;

e. Cosmetic and grooming items and services in excess of those included in the basic service;

f. Personal clothing, reading materials, gifts, and/or room accoutrement including flowers, plants, hanging pictures or decorations;

g. Social events and activities beyond the facility's established program; and/or

i. Special care services not included in the facility's Medicaid payment rate.

3. Payer of last resort -- Medicaid is the payer of last resort for all NF services.

a. Full dual eligible Medicare and Medicaid eligible beneficiaries. Medicaid payment for NF services provided to Medicaid-Medicare dually eligible beneficiaries is only available if Medicare payment is not available. The State pays the Medicare premiums and co-insurance and deductibles for dual eligible beneficiaries with income up to 100 percent of the federal poverty level (FPL) or who are medically needy eligible for LTSS and do not include such Medicare costs toward their monthly spenddown.

b. Partial dual eligible beneficiaries. Medicare beneficiaries who do not qualify for Medicaid LTSS due to excess resources, may apply for Medicaid coverage to cover Medicare co-insurance for skilled services through the State's Medicare Premium Payment Program.

4. Payment authorization - Payment for NF services is based on a per diem rate. Accordingly:

a. First day. Payment for NF services by the State begins on the first day of eligibility or the date in which the beneficiary is admitted and receiving services, whichever comes later and without regard to the hour of admission.

b. Last day. Payment does not cover NF services on the last day beneficiaries are in a NF, regardless of the hour of discharge from the facility.

c. Bed-hold days. The State does not pay for NF services to retain a bed or placement. When a beneficiary leaves a NF for a hospital stay or any other temporary absence, the State ceases making payment to the facility beginning the day after the beneficiary leaves the NF. NF personnel must notify the State of the beneficiary's departure as soon as possible, but no later than ten (10) business days.

d. PASSR. No authorization for NF payment is made until the PASSR evaluation has been completed.

1.5.1Accessing NF Coverage

A. The State maintains a "No Wrong Door" policy for anyone seeking LTSS. Therefore, an applicant seeking initial Medicaid LTSS eligibility is treated the same irrespective of whether he or she is living at home or in a community-based supportive living arrangement, residing in a NF, or a patient in a hospital or other health institution. Once a determination of LTSS eligibility is completed, services in a NF are authorized providing all other factors affecting access have been met.

B. Certain factors affect access to Medicaid LTSS in a NF, including:

1. Age -- LTSS in a NF is available to eligible beneficiaries who are age twenty-one (21) and older. Medicaid treats LTSS for children and youth under age twenty-one (21) as a separate benefit. There is no difference in the range of NF services Medicaid covers for children and youth who have the applicable level of need.

2. Continuous need for LTSS - To qualify for Medicaid LTSS, an applicant must have an established need continuous long-term care as defined in Subchapter 00 Part 1 of this Chapter;

3. Highest level of need - Medicaid coverage of LTSS in a NF is available only to applicants and beneficiaries who have been determined in the functional/clinical eligibility process to have the highest need for the NF level of care. There are exceptions. Both the functional/clinical eligibility criteria and the exceptions are set forth in Subchapter 00 Part 5 of this Chapter.

4. PASSR - All persons seeking admission to a NF are subject to a PASSR evaluation and, as appropriate, the development of a treatment plan in accordance with Subchapter 00 Part 5 of this Chapter.

C. There are no waiting lists for Medicaid NF services. In accordance with R.I. Gen. Laws Chapter 40-8.10, a beneficiary determined to have the highest NF level of need who is receiving LTSS in a home or community-based (HCBS) setting may request a transfer to a NF if a waiting list for services develops, placement in the HCBS setting fails, or a hospital stay occurs without a re-evaluation of functional/clinical level of need if otherwise still eligible.

210 R.I. Code R. 210-RICR-50-05-1.5