Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1187 - NURSING FACILITY SERVICES › Subchapter H - PAYMENT CONDITIONS, LIMITATIONS AND ADJUSTMENTS › Section 1187.104 - Limitations on payment for reserved beds

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The Department will make payment to a
				  nursing facility 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 subject to the limits in subsection (b). A 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 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 payment for
				  reserved bed days is subject to the following limits:
(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 nursing facility at a rate of 1/3 of
				  the nursing facility's current per diem rate on file with the Department for a
				  hospital reserved bed day if the nursing facility meets the overall occupancy
				  requirements of subparagraph (ii).
(ii) A nursing facility's overall occupancy
				  rate shall equal or exceed the following:
(A)
				  During the rate year 2009-2010, the nursing facility's overall occupancy rate
				  for the rate quarter in which the hospital reserved bed day occurs must equal
				  or exceed 75%.
(B) Beginning with
				  the rate year 2010-2011 and thereafter, the nursing facility's overall
				  occupancy rate for the rate quarter in which the hospital reserved bed day
				  occurs must equal or exceed 85%.
(iii) The Department will calculate a nursing
				  facility's overall occupancy rate for a rate quarter as follows:
(A) The Department will identify the picture
				  date for the rate quarter as specified in §
													1187.96(a)(5) 
				  (relating to price- and rate-setting computations) and the two picture dates
				  immediately preceding this picture date.
(B) The Department will calculate the nursing
				  facility's occupancy rate for each of the picture dates identified in clause
				  (A) by dividing the total number of assessments listed in the facility's CMI
				  report for that picture date by the number of the facility's certified beds on
				  file with the Department on the picture date and multiplying the result by
				  100%. The Department will assign the highest of the three picture date
				  occupancy rates as the nursing facility's overall occupancy rate for the rate
				  quarter.
(C) The Department will
				  only use information contained on a valid CMI report to calculate a nursing
				  facility's overall occupancy rate. If a nursing facility did not submit a valid
				  CMI report for a picture date identified in clause (A), the Department will
				  calculate the nursing facility's overall occupancy rate based upon the valid
				  CMI reports that are available for the identified picture dates. If no valid
				  CMI reports are available for the picture dates identified in clause (A), the
				  nursing facility is not eligible to receive payment for hospital reserve bed
				  days in the rate quarter.
(D) For
				  purposes of this subsection, a valid CMI report is a CMI report that meets the
				  requirements of §
													1187.33(a)(5) and
				  (6) (relating to resident data and picture
				  date reporting requirements).
(iv) If the resident's hospital stay exceeds
				  15 consecutive days, the nursing facility shall readmit the resident to the
				  nursing facility upon the first availability of a bed in the nursing facility
				  if, at the time of readmission, the resident requires the services provided by
				  the nursing facility.
(v) If the
				  resident's hospital stay is less than or equal to 15 consecutive days, the
				  nursing facility shall readmit the resident to the same bed the resident
				  occupied before the hospital stay regardless whether the nursing facility is
				  eligible for payment for hospital reserved beds under subparagraph (b)(1)(i),
				  if, at the time of readmission, the resident requires the services provided by
				  the nursing facility.
(vi) 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 nursing facility is eligible for
				  payment for hospital reserved beds under subparagraph (b)(1)(i).