Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1189 - COUNTY NURSING FACILITY SERVICES › Subchapter E - PAYMENT CONDITIONS, LIMITATIONS AND ADJUSTMENTS › Section 1189.103 - Limitations on payment for reserved beds

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A county facility may be eligible for
				  payments for a reserved bed when the resident is absent from the nursing
				  facility for a continuous 24-hour period because of hospitalization or
				  therapeutic leave. A county nursing facility shall record each reserved bed for
				  therapeutic leave on the nursing facility's daily census record and MA invoice.
				  When the bed reserved for a resident who is hospitalized is temporarily
				  occupied by another resident, a county nursing facility shall record the
				  occupied bed on the nursing facility's daily MA census record and the MA
				  invoice. During the reserved bed period the same bed shall be available for the
				  resident upon the resident's return to the nursing facility.
(b) The following limits on payment for
				  reserved bed days apply:
(1)
Hospitalization
.
(i) A
				  resident receiving nursing facility services is eligible for a maximum of 15
				  consecutive reserved bed days per hospitalization. The Department will pay a
				  county nursing facility at a rate of 1/3 of the county nursing facility's
				  current per diem rate on file with the Department for a hospital reserved bed
				  day.
(ii) A county nursing
				  facility's overall occupancy must meet the occupancy requirements in this
				  subparagraph. For each rate quarter, the criteria for meeting the overall
				  occupancy limits will be calculated and applied to the rate quarter based on
				  the highest of the overall occupancy calculated for three picture dates. The
				  three picture dates will be the picture date for the current rate quarter (July
				  1 rate quarter-February 1 picture date; October 1 rate quarter-May 1 picture
				  date; January 1 rate quarter-August 1 picture date; and April 1 rate
				  quarter-November 1 picture date) and the two picture dates directly preceding
				  this picture date. Overall occupancy for each picture date will be calculated
				  by dividing the total number of assessments listed in the facility's CMI report
				  for the picture date by the number of the facility's certified beds on file
				  with the Department on the picture date. The highest of the results will be
				  used to determine whether the county nursing facility meets the overall
				  occupancy criteria set forth as follows:
(A)
				  During rate year 2009-2010, the county nursing facility's overall occupancy
				  rate for the rate quarter in which the hospital reserved bed day occurred must
				  be equal or exceed 75%.
(B)
				  Beginning with rate year 2010-2011 and thereafter, the county nursing
				  facility's overall occupancy rate for the rate quarter in which the hospital
				  reserved bed day occurs must equal or exceed 85%.
(iii) County nursing facilities not
				  submitting a valid CMI report for the three picture dates do not meet the
				  criteria for payment for reserved bed days, unless subparagraph (iv)
				  applies.
(iv) New county nursing
				  facilities are eligible for payment for reserved bed days as set forth in
				  subparagraph (i) until CMI Reports for the three picture dates used to
				  calculate overall occupancy as set forth in subparagraph (ii) are available for
				  the rate quarter.
(v) If the
				  resident's hospital stay exceeds 15 consecutive days, the county nursing
				  facility shall readmit the resident to the nursing facility upon the first
				  availability of a bed in the county nursing facility if, at the time of
				  readmission, the resident requires the services provided by the county nursing
				  facility.
(vi) If the resident's
				  hospital stay is less than or equal to 15 consecutive days, the county nursing
				  facility shall readmit the resident to the same bed the resident occupied
				  before the hospital stay regardless whether the county nursing facility is
				  eligible for payment for hospital reserved beds under subparagraph (b)(1)(ii),
				  if, at the time of readmission, the resident requires the services provided by
				  the nursing facility.
(vii)
				  Hospital reserved bed days may not be billed as therapeutic leave days and may
				  not be billed to the resident if the resident's hospital stay is less than or
				  equal to 15 consecutive days regardless whether the county nursing facility is
				  eligible for payment for hospital reserved beds under subparagraph
				  (b)(1)(ii).