Ohio Admin. Code 5123-7-08 - Intermediate care facilities for individuals with intellectual disabilities - bed-hold days
Current through all regulations passed and filed through March 11, 2022
(A)
Purpose
(B)
Definitions
(1)
"Admission" occurs when an individual who was not being
counted in the census of any Ohio medicaid-certified ICFIID becomes a resident
of an ICFIID. An admission may be a new admission or a return admission after a
discharge.
(2)
"Advanced practice registered nurse" has the same
meaning as in section
4723.01 of the
Revised Code.
(3)
"Bed-hold day" means a day for which a bed is reserved
for a resident of an ICFIID through medicaid reimbursement while the resident
is temporarily absent from the ICFIID for hospitalization, therapeutic leave,
or a visit with friends or relatives. Reimbursement for bed-hold days may be
made only if the resident has the intent and ability or may have cause to
return to the same ICFIID. A resident on bed-hold day status is not considered
discharged because the ICFIID is reimbursed to hold the bed while the resident
is on temporary leave.
(4)
"Business day" means a day of the week, excluding
Saturday, Sunday, or a legal holiday as defined in section
1.14
of the Revised Code.
(5)
"Discharge" means the full release of a resident from
an ICFIID so that he or she is no longer counted in the ICFIID's census.
Reasons for discharge include, but are not limited to, the resident's move to
another ICFIID, decision to reside in a community-based setting, or death. The
day of discharge is not counted as a bed-hold day or an occupied day except
when discharge and admission occur on the same day, in which case the day is
considered a day of admission and counts as one occupied day.
(6)
"Home and
community-based services" has the same meaning as in section
5123.01
of the Revised Code.
(7)
"Hospital" has the same meaning as in rule
3701-59-01 of the
Administrative Code.
(8)
"Hospitalization" means a resident is temporarily
absent from an ICFIID for the purpose of receiving services or being treated in
a hospital.
(9)
"Institution for mental disease" has the same meaning
as in rule 5160-3-16.4 of the Administrative Code.
(10)
"Occupied day"
means either:
(a)
A day of admission; or
(b)
A day during
which a medicaid-eligible resident's stay in an ICFIID is eight or more hours.
A day begins at twelve a.m. and ends at eleven fifty-nine
p.m.
(11)
"Readmission" occurs when a resident returns to the
same ICFIID following use of bed-hold days.
(12)
"Skilled nursing
facility" means a nursing facility certified to participate in the medicare
program.
(13)
"Therapeutic leave" means a resident is temporarily
absent from an ICFIID, and is in a residential setting other than a long-term
care facility, hospital, or other entity eligible to receive federal, state, or
county funds to maintain a resident, for the purpose of receiving a regimen of
therapeutic services or visiting a potential new residential
setting.
(C)
Prohibition of preadmission bed-hold payment
(1)
The department
shall not make payment to an ICFIID to reserve a bed for a medicaid-eligible
prospective resident.
(2)
An ICFIID shall not accept preadmission payment to
reserve a bed from a medicaid-eligible prospective resident or from any other
source on the prospective resident's behalf as a precondition for
admission.
(D)
Limits and reimbursement for bed-hold days
(1)
For a
medicaid-eligible resident of an ICFIID, except those excluded in accordance
with paragraph (H) of this rule, the department may reimburse the ICFIID to
reserve a bed only for as long as the resident has a developmental disabilities
level of care determination and intends or may have cause to return to the same
ICFIID, but not for more than thirty days in any calendar year unless
additional days have been authorized by the department in accordance with
paragraph (E) of this rule.
(2)
Reimbursement for
bed-hold days shall be paid at one hundred per cent of the ICFIID's per diem
rate.
(3)
Reimbursement for bed-hold days may be made for the
following reasons:
(a)
Hospitalization
(i)
The day the
resident's anticipated level of care at time of discharge from the hospital
changes to a level of care that the ICFIID is not certified to
provide;
(ii)
The day the resident is discharged from the hospital,
including discharge resulting in transfer to the ICFIID, a nursing facility, or
a skilled nursing facility;
(iii)
The day the
resident decides to go to another ICFIID upon discharge from the hospital and
notifies the first ICFIID; or
(iv)
The day the
hospitalized resident dies.
(b)
Therapeutic
leave
(i)
A plan
to use bed-hold days for therapeutic leave for the purpose of receiving a
regimen of therapeutic services must be approved in advance by a physician or
an advanced practice registered nurse and documented in the resident's medical
record. The documentation shall be available for viewing by the
department.
(ii)
A plan to use bed-hold days for therapeutic leave for
the purpose of visiting a potential new residential setting must be approved in
advance by a physician, an advanced practice registered nurse, or a qualified
intellectual disability professional and documented in the resident's medical
record or individual plan. The documentation shall be available for viewing by
the department.
(iii)
An ICFIID shall make arrangements for the resident to
receive required care and services while on approved therapeutic leave.
Medicaid funding, however, shall not be used for state plan home health
services, durable medical equipment, and/or private duty nursing on days for
which the ICFIID receives reimbursement for bed-hold days.
(c)
Visit
with friends or relatives
(i)
A plan to use bed-hold days to visit with friends or
relatives must be approved in advance by a physician, an advanced practice
registered nurse, or a qualified intellectual disability professional and
documented in the resident's medical record or individual plan. The
documentation shall be available for viewing by the department.
(ii)
An ICFIID shall
make arrangements for the resident to receive required care and services while
on approved visits. Medicaid funding, however, shall not be used for state plan
home health services, durable medical equipment, and/or private duty nursing on
days for which the ICFIID receives reimbursement for bed-hold
days.
(iii)
The number of days per visit is flexible within the
maximum bed-hold days, allowing for differences in the resident's physical
condition, the type of visit, and travel time.
(4)
The
number and frequency of bed-hold days used shall be considered in evaluating
the continuing need of a resident for care in an ICFIID.
(E)
Requests for additional bed-hold days
(1)
Additional
bed-hold days beyond the original thirty days in a calendar year require prior
authorization except in the event of an emergency situation. In the event of an
emergency situation, authorization may be requested after the fact if the
request is submitted no later than one business day following the first
additional bed-hold day. A maximum of thirty additional consecutive bed-hold
days may be authorized per request.
(2)
An ICFIID shall
submit a request for additional bed-hold days to the department electronically
via the department's website. The request shall be consistent with the goals of
the resident's individual plan and medical records and include:
(a)
Reason for
bed-hold days (i.e., hospitalization, therapeutic leave, or visit with friends
or relatives);
(b)
Projected dates of absence; and
(c)
Projected date of
return.
(3)
The department shall review the request for additional
bed-hold days and send notice within five business days of approval or denial
to the ICFIID.
(a)
When a request is approved, the notice shall specify
the time period during which the bed-hold days may be used.
(b)
When a request is
denied, the notice shall specify the reason for denial and explain the
individual's right to a state hearing in accordance with section
5101.35 of the Revised
Code.
(4)
The department shall review requests for additional
bed-hold days on a case-by-case basis. Conditions under which a request may be
denied include, but are not limited to, visits with friends or relatives
exceeding thirty consecutive days or forty-five total days in a calendar
year.
(5)
An approved request for additional bed-hold days is for
the specified period of time only. Unused bed-hold days from an approved
request shall not be used at a later time. A new request must be submitted if
additional bed-hold days are required during that same calendar
year.
(6)
Bed-hold days beyond the original thirty days used
without prior authorization by the department may result in an adjustment to
the ICFIID's reimbursement.
(F)
Readmission
(G)
Residents eligible for bed-hold days
(1)
Medicaid
reimbursement for bed-hold days is available under the provisions specified in
this rule if a resident:
(a)
Is eligible for medicaid services and has met the
patient liability and financial eligibility requirements set forth in Chapter
5160:1-6 of the Administrative Code;
(b)
Requires a
developmental disabilities level of care; and
(c)
Is not excluded
in accordance with paragraph (H) of this rule.
(2)
If a resident
meets all of the criteria in paragraph (G)(1) of this rule and is pending
approval of a medicaid application and requires bed-hold days, medicaid
reimbursement shall be made retroactive to the date the resident became
medicaid-eligible and approved for medicaid vendor reimbursement through the
date the resident returns from a leave or until the maximum number of bed-hold
days are exhausted.
(H)
Exclusions
(1)
Enrolled in a
medicare or medicaid hospice program;
(2)
Over age
twenty-one and under age sixty-five and becomes a patient of an institution for
mental disease;
(3)
Enrolled in a home and community-based services
waiver;
(4)
In a period of restricted medicaid coverage because of
an improper transfer of resources as set forth in rule 5160:1-6-06.5 of the
Administrative Code; or
(5)
Relocating due to anticipated closure of an ICFIID, an
ICFIID's voluntary withdrawal from participation in the medicaid program, or
other events that result in termination of an ICFIID's medicaid provider
agreement except when the ICFIID becomes a downsized ICFIID as defined in
section
5124.01 of the
Revised Code or converts beds from ICFIID services to home and community-based
services in accordance with section
5124.60
or
5124.61
of the Revised Code. No span of bed-hold days shall be approved that ends on an
ICFIID's date of closure or termination from participation in the medicaid
program.
(I)
Compliance
(1)
Without limiting such other remedies provided by law
for noncompliance with this rule:
(a)
The Ohio department of medicaid may terminate the
ICFIID's provider agreement; or
(b)
The department
may require the ICFIID to submit and implement a corrective action plan on a
schedule specified by the department.
(2)
An ICFIID shall
cooperate with any investigation and shall provide copies of any records
requested by the department or the Ohio department of medicaid.
Replaces: 5123:2-7-08
Notes
Promulgated Under: 119.03
Statutory Authority: 5123.04, 5124.03, 5124.34
Rule Amplifies: 5123.04, 5124.03, 5124.34
Prior Effective Dates: 01/10/2013, 07/01/2016
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