Or. Admin. R. 411-070-0130 - Medicaid Payment in Hospitals

(1) SWING BED ELIGIBILITY. To be eligible to receive a Medicaid payment under this rule, a hospital must:

(a) Have approval from the Centers for Medicare and Medicaid Services (CMS) to furnish skilled nursing facility services as a Medicare swing-bed hospital;

(b) Have a Medicare provider agreement for acute care; and

(c) Have a current signed provider agreement with SPD to receive Medicaid payment for swing-bed services.

(2) NUMBER OF BEDS.

(a) A critical access hospital (CAH) not located within a 30 mile geographic radius of a licensed nursing facility as of March 13, 2007 may receive Medicaid payment for up to 20 residents at one time. The CAH must maintain at least five beds or twice the average acute care daily census, whichever is greater, for exclusive acute care use.

(b) Other hospitals receiving payment for Medicaid services under this rule may not receive Medicaid payment for more than a total of five residents at one time. In addition, the residents must have a documented need for and receive services that meet the complex medical add-on requirements outlined in OAR 411-070-0091.

(c) If circumstances change so that a CAH receiving payment for Medicaid services pursuant to section (2)(b) of this rule meets the criteria set out in section (2)(a) of this rule after March 13, 2007, the CAH may petition SPD for authorization to receive such payment pursuant to section (2)(a) of this rule. SPD shall evaluate all available long-term care resources within a 30 mile geographic radius of the CAH and the amount of unmet long-term care need in the same area and determine if the CAH shall be authorized to receive payment pursuant to section (2)(a) of this rule.

(3) SERVICES PROVIDED. The daily Medicaid rate shall be for the services outlined in OAR 411-070-0085 (Bundled Rate).

(4) COMPLIANCE WITH MEDICAID REQUIREMENTS. Hospitals receiving Medicaid payment for swing-bed services must comply with federal and SPD rules and statutes that affect long-term care facilities as outlined in the facility's provider agreement with SPD.

(5) ADMISSION OF INDIVIDUALS. Prior to determination of Medicaid payment eligibility in the swing bed, the case manager must determine there is no nursing facility bed available to the individual within a 30 mile geographic radius of the hospital. For the purpose of this rule, "available bed" means a bed in a nursing facility that is available to the individual at the time the placement decision is made.

Notes

Or. Admin. R. 411-070-0130

SSD 7-1988, f. & ef. 7-1-88; SSD 20-1990, f. & cert. ef. 10-4-90; SSD 6-1993, f. 6-30-93, cert. ef. 7-1-93; SSD 1-1997, f. 6-30-97, cert. ef. 7-1-97; SPD 9-2006, f. 1-26-06, cert. ef. 2-1-06; SPD 1-2007, f. 3-12-07. & cert. ef. 3-13-07; SPD 15-2009, f. 11-30-09, cert. ef. 12-1-09

Stat. Auth.: ORS 410.070

Stats. Implemented: ORS 410.070 & 414.065