Current through Register Vol. 50, No. 9, September 20, 2024
A.
Residents Receiving Care Under Title XIX (Medicaid) Only
1. The BHSF Medicaid Program shall determine
the resident's applicable income (liability when computing facility vendor
payments. Vendor payments are subject to the following conditions.
a. Vendor payments shall begin with the first
day the resident is determined categorically and medically eligible or the date
of admission, if later.
b. Vendor
payments shall be made as determined by the facility per diem rate less the
resident's per diem applicable income for the number of eligible
days.
c. If a resident transfers
from one facility to another, the vendor payments to each facility is the
facility's per diem rate for the number of days in the facility, less the
resident's per diem applicable income for the total number of days in each
facility.
2. Retroactive
Payment. When individuals enter a facility before their Medicaid eligibility
has been established, payment for facility services is made retroactive to the
first date of eligibility after admission.
3. Resident Personal Care Income. The
facility shall not require that any part of a resident's personal care income
be paid as a part of the facility's fee. Personal care income is an amount set
aside from a resident's available income to be used for personal needs. The
amount is determined by the Department of Health and Hospitals.
a. The facility shall not permit tips for
services rendered by facility employees.
B. Residents Receiving Care Under Title XVIII
(Medicare). Resident income shall not be considered in determining vendor
payments for a period of up to 100 days provided he/she remains eligible for
Title XVIII-A (Medicare). This also includes the period for which coinsurance
is being paid by the Medicaid Program.
C. Timely Filing For Reimbursements. Vendor
payments cannot be made when more than 12 months have elapsed between the month
of initial service and submittal of a claim for these services. Payment of
claims more than 12 months old require the approval of the Bureau of Health
Services Financing Program Operations Section.
D. Temporary Absence of the Resident; No
Evacuation. Payment procedures for periods of temporary absnce are subject to
the following conditions.
1. The facility
keeps a bed available for the resident's return and provides notification in
accordance with the Bed Reservation Policy requirements in the chapter entitled
Transfer and Discharge Procedures.
2. The absence is for one of the following
reasons:
a. hospitalization for an acute
condition including psychiatric stays, which does not exceed 5 days per
hospitalization;
b. home leave.
NOTE: Payment cannot be mad for hospital leave days while
a resident is receiving swing bed SNF services.
3. When the hospital has determined that
discharge is appropriate for a resident who had been admitted to the hospital
from a nursing facility, the nursing facility shall readmit this resident on
the date the physician writes the discharge regardless of the hour of the day
or the day of the week. This includes holidays and weeks.
4. Payment will not be made to the nursing
facility for hospital leave days beyond the date of the physician's date of
discharge from the hospital.
5.
Home leave (leave of absence), is defined as a visit with relatives or friends
which does not exceed 9 days per calendar year. Institutionalization is not
broken if the absence does not exceed 14 days and if the facility has not
discharged the resident.
NOTE: Elopements (unauthorized absences under the plan of
care) count against allowable home leave days.
6. The period of absence shall be determined
by counting the first day of absence as the day the resident leaves the
facility.
7. Only a period of 24
continuous hours or mroe shall be considered an absence. Likewise, a temporary
leave of absence for hospitalization or home visit is broken only if the
resident returns to the facility for 24 hours or longer.
8. Upon admission, a resident must remain in
the facility at least 24 hours in order for the facility to submit a payment
claim for a day of service or reserve a bed.
EXAMPLE: A resident admitted to a nursing facility in the
morning and transferred to the hospital that afternoon would not be eligible
for any vendor payment for facility services.
9. If a resident transfers from one facility
to another, the unused home leave days for that calendar year also transfer. No
additional leave days are allocated.
10. The facility shall promptly notify the
Parish/Regional BHSF Office of absences beyond the applicable, 14, 5, or 4 day
limitations.
E.
Temporary Absence Due To Evacuation. When local conditions require evacuation
of residents in nursing facilities, the following payment procedures apply.
1. When the resident is evacuated for less
than twenty four (24) hours, the monthly vendor payment to the facility is not
interrupted.
2. When the staff is
sent with the resident(s) to the evacuation site, the monthly vendor payment to
the facility is not interrupted.
3.
When the resident is evacuated to family or friend's home, at the facility's
request, the facility shall not submit a claim for a day of service or leave
day, and patient liability shall not be collected.
4. When the resident goes home at the
family's request or on their own initiative, a leave day shall be
charged.
5. When the resident is
admitted to the hospital for the purpose of evacuation of the nursing facility,
Medicaid payment shall not be made for the hospital charges.
F. Resident Deposits. A facility
shall neither require nor accept an advance deposit from a resident whose
Medicaid eligibility has been established.
EXCEPTION: A facility may require an advance deposit for
the current month only on the part of the total payment which is the resident's
liability.
1. If advance deposits or
payments are required from residents or residents legal representative or
sponsor upon admission when Medicaid eligibility has not been established, then
such a deposit shall be refunded or credited to the person upon receipt of
vendor payment.
2. Credit on the
facility's books in lieu of a refund to the resident or resident's legal
representative or sponsor is acceptable within the following limitations:
a. Such credit shall not exceed an amount
equal to the resident's liability for 60 days following the date the resident
was determined eligible for Medicaid.
b. Any deposit exceeding such an amount shall
be refunded within five working days to the resident or resident's legal
representative or sponsor.
G. Refunds to Bureau of Health Services
Financing Medicaid Program
1. A
Non-Participating Facility. Vendor payments made for the services performed
while a facility is in a non-participating status shall be refunded to the
Department of Health and Hospitals, Office of Management and Finance. The
refund shall be made payable to the Bureau of Health Services Financing
Medicaid Program.
2. A
Participating Facility. A currently participating Medicaid facility shall
correct billing or payment errors by the use of appropriate Adjustment/Void or
Resident Liability (PLI) adjustment form.
H. Refunds to Residents. Advance payments for
a resident's liability (applicable income) shall be refunded promptly if he/she
leaves the facility before the end of the month. The facility shall adhere to
the following procedures for the refunds.
1.
The proportionate amount for the remaining days of the month shall be refunded
to the resident or the resident's legal representative or sponsor no later than
the end of the month following discharge. If the resident has not yet been
certified, then the procedures spelled out in Refunds to Residents, paragraph
one, shall apply.
2. No penalty
shall be charged to the resident or resident's legal representative or sponsor
even if the circumstances surrounding the discharge occurred as follows:
a. without prior notice;
b. within the initial month; and
c. within some other "minimum stay" period
established by the facility.
3. Proof of refund of the unused portion of
the applicable income shall be furnished to the BHSF Medicaid Program upon
request.
AUTHORITY NOTE:
Promulgated in accordance with
R.S.
46:153.
