Pennsylvania Code
Title 55 - HUMAN SERVICES
Part III - MEDICAL ASSISTANCE MANUAL
Chapter 1187 - NURSING FACILITY SERVICES
Subchapter L - NURSING FACILITY PARTICIPATION REQUIREMENTS AND REVIEW PROCESS
BED REQUESTS
Section 1187.176 - Criteria for the approval of bed requests other than bed transfer requests
Universal Citation: 55 PA Code ยง 1187.176
Current through Register Vol. 54, No. 44, November 2, 2024
(a) The Department may approve a bed request, other than a bed transfer request, only if the following are satisfied:
(1) The bed request
contains the information required under §
1187.172(a)
(relating to contents and submission of bed requests).
(2) The additional MA-certified nursing
facility beds are needed in the primary service area or the county in which the
subject facility is located to maintain or improve MA recipients' access to
medically necessary nursing facility services based on any of the following:
(i) The existing MA-certified bed capacity in
the primary service area or the county in which the subject facility is or will
be located is insufficient to assure that MA recipients have access to
medically necessary nursing facility services.
(ii) Systemic barriers prevent MA recipients
from accessing the existing MA-certified bed capacity in the primary service
area or the county in which the subject facility is or will be
located.
(iii) The applicant is
proposing to admit and serve MA recipients who require specialized medical
services in the subject facility and MA recipients do not have access to the
specialized medical services in the existing MA-certified bed capacity in the
primary service area or the county in which the subject facility is or will be
located.
(3) The legal
entity agrees, in a form acceptable to the Department, to the following:
(i) The subject facility will admit and serve
MA day-one recipients.
(ii) The
subject facility will maintain an MA occupancy rate that equals or exceeds the
average MA occupancy rate of MA nursing facilities in the county in which the
subject facility is or will be located or, in the case of a subject facility
that is proposing to offer specialized medical services, the MA occupancy rate
as may be agreed to by the Department.
(iii) The construction and operation of the
new or additional beds will be economically and financially feasible without
the receipt of MA fixed property capital component payments, and it is not
entitled to MA capital component payments for fixed property related to the new
or additional beds.
(4)
None of the circumstances specified in § 1187.172(a)(4) applies.
(b) In determining whether a need for additional MA-certified beds exists under subsection (a), the following will apply:
(1) MA-certified bed capacity
will be deemed sufficient if the average annual overall occupancy rates of
providers in the primary service area and county in which the subject facility
is or will be located is 95% or less, based on the most recent MA cost report
data submitted by those providers.
(2) If the average annual overall occupancy
rates of providers in the primary service area or county in which the subject
facility is located exceeds 95%, based on the most recent MA cost report data
submitted by those providers, the Department will consider the following
information in assessing whether a need for additional MA-certified beds exits:
(i) The total number of MA-certified nursing
facility beds in the primary service area.
(ii) The total number of licensed nursing
facility beds in the primary service area.
(iii) The annual overall occupancy rates of
providers in the primary service area based on the most recent MA cost report
data submitted by those providers.
(iv) The annual actual bed days in the
primary service area for the most recent 3-year period including the most
recent cost report period, as submitted by nursing facility providers in the
primary service area.
(3)
No systemic barrier that prevents MA recipients from accessing MA-certified bed
capacity will be deemed to exist if the average MA occupancy rate and the
average MA day-one admission rate of providers in the primary service area and
county in which the subject facility is or will be located are above the
Statewide average rates or within one percentage point below the Statewide
rates.
(c) The Department may deny a bed request even if the conditions specified in subsection (a) are satisfied if the Department determines one of the following:
(1) Approval of the request would negatively
affect the Department's goal to rebalance the Commonwealth's publicly-funded
long-term living system to create a fuller array of service options for MA
recipients.
(2) There are
alternatives to the bed request, such as an increase in home and
community-based services, that would be less costly, more efficient or more
appropriate in assuring that long-term living care and services will be
provided under the MA Program in a manner consistent with applicable Federal
and State law.
This section cited in 55 Pa. Code § 1187.172 (relating to contents andn submission of bed requests).
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