Please also read attachments 42 CFR �489.22, Special provisions applicable to prepayment requirements.
(a) A provider may not require an individual entitled to hospital insurance benefits to prepay in part or in whole for inpatient services as a condition of admittance as an inpatient, except where it is clear upon admission that payment under Medicare, Part A cannot be made. (b) A provider may not deny covered inpatient services to an individual entitled to have payment made for those services on the ground of inability or failure to a pay a requested amount at or before admission. (c) A provider may not evict, or threaten to evict, an individual for inability to pay a deductible or a coinsurance amount required under Medicare. (d) A provider may not charge an individual for (1) its agreement to admit or readmit the individual on some specified future date for covered inpatient services; or (2) for failure to remain an inpatient for any agreed-upon length of time or for failure to give advance notice of departure from the provider's facilities. Lita D. Atkinson 770-330-2857 ---------- In a message dated 1/20/2004 3:53:33 AM Eastern Standard Time, DB0853 writes: > > Subj: deposits for Med A residents? > Date: 1/20/2004 3:53:33 AM Eastern Standard Time > From: [EMAIL PROTECTED] > To: [EMAIL PROTECTED] > Reply-To: [EMAIL PROTECTED] > Sent from the Internet (Details) > > > Does anyone have a copy of the email from last week that refers to the regulations > about asking for deposits as a condition of admission. Its very important to get a > copy that > those regs. Please check your archives and forward it. > > thank you. > >Title: CCH Internet Research NetWork
TRANS-LETTER, MED-GUIDE ,264, Bed-Hold Policies for Long-Term Care Facilities, (Feb. 1, 1999)Bed-Hold Policies for Long-Term Care Facilities Intermediary Manual, HCFA Pub. 13-3 Transmittal No. 1768 Feb. 1, 1999 Part A --Provider services --Limitations on coverage. -- Post-admission bed-hold payments are distinguishable from payments for readmission to Medicaid nursing facilities, and thereby permissible. Such charges must be for holding a bed rather than for an act of readmission. Payments made prior to an initial admission are distinguishable from post-admission bed-hold payments made during a temporary absence from a nursing facility because, under the latter, an individual has already established residence. See 9, 724. Section 3314.1, Bed-Hold Policies for Long-Term Care Facilities, explains policies regarding bed-hold payments made during a resident's absence from a Medicaid nursing facility (NF) or a Medicare skilled nursing facility (SNF). It clarifies that post-admission bed-hold payments are distinguishable from payments for readmission (and thereby permissible) if they do, in fact, represent charges to hold the bed rather than a charge for the act of readmission. Payments made prior to initial admission are distinguishable from post-admission bed-hold payments made during a temporary absence from the facility in that, under the latter, the individual has already established residence in the facility. This transmittal manualizes PM 94-2 (Regional Office, General), dated July 1994, which has since been obsoleted. These instructions should be implemented within your current operating budget. DISCLAIMER: The revision date and transmittal number only apply to the redlined material. All other material was previosly published in the manual and is only being reprinted. [CCH Note: revised text is shown in italics.] F. Other Restrictions and Requirements. --Medicare regulations include several other special limitations that are covered by or based on the provider agreement: l A provider may not evict or threaten to evict a beneficiary for inability to pay a deductible or coinsurance amount applying under Medicare; l A provider may not charge a beneficiary for agreeing to admit or readmit him/her as of some specified future date for inpatient services which are or may be covered under Medicare (as distinguished from charging for holding a bed for him/her at his/her request as is permissible); and l A provider may not charge a beneficiary who is receiving inpatient hospital care which is or may be covered by Medicare for failure to remain in the facility for a certain period of time or for failure to give advance notice of departure. If the provider requires the execution of an admission contract by the beneficiary (or by another person acting on behalf of the beneficiary), make sure that the terms of the contract are consistent with this section. G. Compliance. --Providers must conform to the restrictions and requirements of this section or face termination of their provider participation agreements. Initiate investigations based on beneficiary complaints or other indications of violations. The HCFA regional offices (ROs) may refer beneficiary complaints to you for investigation. You are entitled to examine and copy provider billing and other records relevant to your investigation. (Failure of the provider to cooperate may afford a basis for a presumptive finding against the provider.) Make reports to the RO on the results of your investigation. Improper charges to beneficiaries under the above restrictions and requirements constitute violations of the provider agreement under 6(a)(1) of the Act. If one or more violations are established, the RO asks the provider to advise the RO in writing within a specified period of time, e.g., within 15 days, that there will be no further violations, and that any existing violations will be corrected promptly, or face termination of its provider agreement. If the requested commitment is not received, the RO may terminate the provider agreement. If the commitment is received, but the violations are not fully corrected, or there are subsequent violations, the RO may, depending on the nature and extent of the violations, terminate the provider agreement. Under 9(d)(4)(A) of the Act, an SNF violates the conditions of participation if it fails to operate and provide services in compliance with all applicable Federal, State and local laws and regulations, including the Federal statutory requirements and regulations which are the basis of the above restrictions and requirements. Section 1819(h) of the Act authorizes a number of alternative remedies to be imposed on SNFs that fail to comply with Federal participation requirements, in lieu of, or in addition to, termination of the provider agreement. In the case of SNFs 9(h)(2)(B)(i) and (ii) gives the RO as an alternative to termination of the provider agreement the authority to deny Medicare payments for new admissions and/or to fine the SNF up to $10,000 a day as long as the violations continue or are not corrected. If the initial finding of violations by an SNF indicates extreme abuse, the RO may move to impose sanctions without first asking for a commitment by the SNF to desist from those violations. The State agency, usually the State health department, which surveys SNFs for compliance with the conditions of participation, also monitors SNFs for compliance with the above requirements and restrictions and reports its findings to the RO. 3314.1 Bed-Hold Policies for Long Term Care Facilities. --These instructions summarize the policies regarding bed-hold payments made during a resident's absence from a Medicaid nursing facility (NF) or Medicare skilled nursing facility (SNF). Post-admission bed-hold payments are distinguishable from payments for readmission (and thereby permissible) if they represent charges to hold the bed rather than a charge for the act of readmission itself. Similarly, payments made prior to initial admission are distinguishable from post-admission bed-hold payments made during a temporary absence from the facility in that, under the latter, the individual has already established residence in a particular living space within the facility (see 4.F. and 4.1.B.2). A. Medicaid. -- 1. Law and Regulations. --Under Medicaid payment regulations at 42 CFR 447.40, Federal financial participation is available if a State plan includes provision for bed-hold payments during a recipient's temporary absence from an inpatient facility. (To qualify under this provision, an absence for any purpose other than required hospitalization must be provided for in the patient's plan of care.) However, under 42 CFR 447.40(a)(1), Medicaid can make bed-hold payments only if the State plan provides for them and specifies any limitations on the policy. To satisfy Medicaid's NF requirements for participation in 9(c)(2)(D)(i)-(ii) of the Act, and in 42 CFR 483.12(b)(1)-(2), an NF must tell residents departing for hospitalization or therapeutic leave about the State's bed-hold payment policy. (This information must be in writing and must specify the number of days the State Medicaid program covers, if any, and the NF's policy regarding bed-hold periods.) If a Medicaid eligible resident's absence from the NF exceeds the bed-hold period provided in the State plan, 9(c)(2)(D)(iii) of the Act, and 42 CFR 483.12(b)(3), guarantee the resident readmission to the facility immediately upon the first availability of a bed in a semi-private room in the facility if, at the time of readmission, the resident requires the services provided in the facility. The Medicaid NF requirements for participation in 9(c)(5)(A)(iii) of the Act, and 42 CFR 483.12(d)(3), prohibit a NF from accepting any gift, money, donation, or other consideration as a precondition for a Medicaid eligible individual's admission, expedited admission, or continued stay in the facility. The Medicaid NF requirements for participation in 9(c)(1)(B)(iii)-(iv) of the Act, and 42 CFR 483.10(b)(5)-(6), requires an NF to inform each resident, upon admission and periodically thereafter, of services which the resident can be charged, as well as the amount of the charge. 2. Interpretation. --The Medicaid program does not make payment to reserve a bed before a prospective resident's initial admission to a facility since 42 CFR 447.40 provides authority for Medicaid bed-hold payments only after an individual has been admitted to the facility. Further, under 9(c)(5)(A)(iii) of the Act and 42 CFR 483.12(d)(3), an NF may not accept preadmission bed-hold payments from a Medicaid eligible prospective resident or from any other source on that individual's behalf. The Medicaid prohibition on preadmission payments does not apply to private pay patients. Under Medicaid, the prohibition on accepting preadmission payments (see 42 CFR 483.12(d)(3)) applies only in connection with individuals who are, in fact, Medicaid eligible. If an individual is admitted as a private pay resident, and the Medicaid agency then makes a retroactive eligibility determination that extends back to include the preadmission period, the NF at that point should refund any preadmission payments it had collected with regard to that individual for the period covered by the Medicaid eligibility determination. When a Medicaid eligible individual who has been admitted to the facility takes a temporary leave of absence from the facility, Medicaid can make bed-hold payments under 42 CFR 447.40. However, under 42 CFR 447.40(a)(1), Medicaid can make such payments only if the State plan provides for them and specifies any limitations on the policy. Bed-holds for days of absence in excess of the State's bed-hold limit are considered noncovered services for which the resident may elect to pay. (Under 9(c)(1)(B)(iii) of the Act and 42 CFR 483.10(b)(5)-(6), the facility must inform residents in advance of the period for which Medicaid payments will be made for the holding of a bed, their option to make bed-hold payments if hospitalized or on a therapeutic leave beyond the State's bed-hold period, and the amount of the facility's charge. For these optional payments, the facility should make clear that the resident must affirmatively elect to make them prior to being billed; a facility cannot simply deem a
resident to have opted to make such payments and then automatically bill for them upon the resident's discharge.) Thus, a Medicaid eligible resident whose absence from the facility exceeds the State's bed-hold limit can elect either to: l Ensure the timely availability of a specific bed upon return by making bed-hold payments for any days of absence in excess of the State's payment limit; or l Return upon the first availability of a semi-private bed in the facility in accordance with 9(c)(2)(D) of the Act and 42 CFR 483.12(b)(3). (The first available semi-private bed refers to the first unoccupied bed, in a room shared with another member of the same sex, that is not being held because a resident (regardless of the source of payment) has elected to make payment to hold the bed.) An NF may not impose a minimum bed-hold charge (e.g., a 3-day minimum charge on all bed reservations) because such minimum charges may result in duplication of Medicaid payments for covered services. Further, a bed-hold period should not be appended routinely at the end of each resident's stay without regard to whether the resident's impending departure from the facility will be temporary or permanent; rather, such program payments are appropriate only in those instances where there is a genuine expectation that a particular recipient actually will return to the facility within a reasonable period of time. B. Medicare. -- 1. Law and Regulations. --The Medicare SNF requirements for participation (see 9 of the Act) contain no provisions corresponding to those of the Medicaid statute in 9(c)(2)(D), and (c)(5)(A)(iii) of the Act. Unlike the Medicaid regulations at 42 CFR 447.40, the Medicare regulations do not include any provisions authorizing the program to make bed-hold payments. The Medicare SNF requirements for participation in 9(c)(1)(B)(iii) of the Act and at 42 CFR 483.10(b)(5)-(6), require a SNF to inform each resident, upon admission and periodically thereafter, of services for which the resident can be charged, as well as the amount of the charge. Under the Medicare provider agreement requirements in 6(a)(2)(B) of the Act and at 42 CFR 489.32(a)(2), a SNF may charge a resident for services in excess of (or more expensive than) covered services only when the services are furnished at the resident's request. The Medicare provider agreement regulations at 42 CFR 489.22 spell out the special provisions appicable to prepayment requirements. While 42 CFR 489.22(d)(1) prohibits Medicare providers (including SNFs) from charging for an agreement to admit or readmit an individual on some specified future date for covered inpatient services, 42 CFR 489.22(a) indicates that a provider may require a prepayment when it is clear upon admission that payment under Part A cannot be made. 2. Interpretation. --Like Medicaid, Medicare does not make bed-hold payments prior to a prospective resident's initial admission to a facility. Further, under the terms of its Medicare provider agreement, a SNF may not accept pre-admission bed-hold payments from or on behalf of a person in return for admitting that person on some specified future date for covered inpatient services. (However, a SNF would not be barred from accepting a pre-admission bed-hold payment from or on behalf of a person who would clearly be denied Part A payment.) Unlike Medicaid, Medicare has no legal authority to make bed-hold payments even after a person's admission to a facility, and the Medicare SNF requirements for participation do not guarantee a return to the first available semi-private bed in the facility. For SNFs, the Medicare prohibition at 42 CFR 489.22(d)(1) applies only to admissions or readmissions for "covered" inpatient services. According, it would not prohibit pre-admission charges to individuals who are not Medicare eligible, since only Medicare beneficiaries can qualify for program coverage of their care. Thus, the Medicare prohibitions on pre-admission payments do not apply to private pay SNF residents, or to those Medicare beneficiaries who do not meet the requirements for Part A SNF coverage. When temporarily leaving an SNF, a resident can choose to make bed-hold payments to the SNF, as long as the SNF's acceptance of such payment does not represent a prohibited provider practice under 42 CFR 489.22(d)(1). This means that the payment to the SNF is solely for the purpose of reserving the bed during the resident's absence and does not represent a payment for the act of readmission on some future date for covered inpatient services. Under 9(c)(1)(B)(iii) of the Act and 42 CFR 483.10(b)(5)-(6), the facility must inform residents in advance of their option to make bed-hold payments, as well as the amount of the facility's charge. For these optional payments, the facility should make clear that the resident must affirmatively elect to make them prior to being billed; a facility cannot simply deem a resident to have opted to make such payments and then automatically bill for them upon the resident's departure from the facility. As noted previously, 42 CFR 489.22(d)(1) prohibits charging a Medicare beneficiary for admission (or readmission) on some specified future date for covered inpatient services. However, when a Medicare-eligible resident leaves a facility temporarily, it is possible to distinguish between prohibited payments made for the act of admission (or readmission) itself and permissible payments made for holding a resident's bed during the resident's temporary absence. Bed-hold payments are readily distinguishable from payments made prior to initial admission, in that the absent individual has already been admitted to the facility and established residence in a particular living space within it. Similarly, bed-hold payments are distinguishable from payments for readmission, in that the latter compensate the facility merely for agreeing in advance to allow a departing resident to reenter the facility upon return, while bed-hold payments represent remuneration for the privilege of actually maintaining the r
esident's personal effects in the particular living space that the resident has temporarily vacated. One indicator that post-admission payments do, in fact, represent permissible bed-hold charges related to maintaining personal effects in a particular living space (rather than a prohibited charge for the act of readmission itself) would be that the charges are calculated on the basis of a per diem bed-hold payment rate multiplied by however many days the resident is absent, as opposed to assessing the resident a fixed sum at the time of departure from the facility. 3315. CERTIFICATION AND RECERTIFICATION BY PHYSICIANS - GENERAL Payments may be made for covered hospital services only if a physician certifies and recertifies to the medical necessity for the services at designated intervals of the hospital inpatient stay. Appropriate supporting material may be required. The physician certification or recertification statement must be based on a current evaluation of the patient's condition. For patients admitted to a general hospital, regardless of whether the patients are under PPS, a physician certification is not required at the time of admission for patient services. For services continued over a period of time or for a day outlier case (i.e., an appropriately admitted case results in an extraordinarily long stay) or for a PPS cost outlier case (i.e., an appropriately admitted case results in the expenditure of extraordinary resources), a physician must certify or recertify the continued need for the services at specified intervals. (See 9 for timing of physician certification and recertification. See 0.7 for definition of outlier.) Psychiatric and tuberculosis hospitals (which are excluded from PPS) are required to obtain a physician certification on admission. Hospitals do not transmit physician certification and recertification statements to the intermediary or to HCFA. The hospital must itself certify on the appropriate billing form that the required physician certification and recertification statements have been obtained and are on file. The physician certification and recertification statements are retained in the hospital's file where they are available for verification if needed. A hospital must also have available in its files a written description of the procedure it adopts on the timing of certifications and recertifications, i.e., the intervals at which the necessary certification statements are required and whether review of long stay cases by the utilization review committee may serve as an alternative to recertification by a physician in the case of the second or subsequent recertification. 3315.1 Failure to Certify or Recertify. --If a hospital fails to obtain the required certification or recertification statements in an individual case, program payments may be made in that case. If the hospital's failure to obtain a certification or recertification is not due to a question as to the necessity for the services, but rather to the physician's refusal to certify based on other grounds (e.g., he/she objects in principle to the concept of certification and recertification), the hospital may not bill the program or the beneficiary for covered items or services. The provider agreement precludes the hospital from charging the patient for covered items and services. 3316. WHO MAY SIGN CERTIFICATION OR RECERTIFICATION A certification or recertification statement must be signed by the attending physician responsible for the case or by another physician who has knowledge of the case and is authorized to do so by the attending physician, or by a member of the hospital's medical staff with knowledge of the case. Ordinarily for purposes of certification and recertification, a "physician" must meet the definition in "3030 and 3030.3. 3316.1 Certification for Hospital Admissions for Dental Services. --The attending doctor of dental surgery or of dental medicine is authorized to certify that the patient's underlying medical condition and clinical status, or the severity of the dental procedure, requires the patient to be admitted to the hospital for the performance of the dental procedure (see 1.7); and to recertify the patient's continuing need for hospitalization when required. This applies even if the dental procedure is not covered. 3317. INPATIENT HOSPITAL SERVICES CERTIFICATION AND RECERTIFICATION A. Contents of Statement. --A certification or recertification statement must contain the following information: l An adequate written record of the reason for either: --Continued hospitalization of the patient for medical treatment or for medically required inpatient diagnostic study, or --Special or unusual services for cost outlier cases for hospitals under the prospective payment system (PPS); l The estimated period of time the patient will need to remain in the hospital and, for cost outlier cases, the period of time for which the special or unusual services will be required; and l Any plans for posthospital care. B. Selection by Hospital of Format and Method for Obtaining Statement. --The individual hospital determines the method by which certifications and recertifications are to be obtained and the format of the statement. Thus, the medical and administrative staffs of each hospital may adopt the form and procedure they find most convenient and appropriate. There is no requirement that the certification or recertification be entered on any specific form or handled in any specific way, as long as the approach adopted by the hospital permits the intermediary (or the Health Care Financing Administration where the hospital deals directly with the government) to determine that the certification and recertification requirements are, in fact, met. The certification or recertification could, therefore, be entered or preprinted on a form the physician already has to sign; or a separate form could be used. If all the required information is included in progress notes, the physician's statement could indicate that the individual's medical record contains the information required and that continued hospitalization is medically necessary. C. Criteria for Continued Inpatient Stay. --A physician who certifies or recertifies to the need for continued inpatient stay should use the same criteria that apply to the hospital's utilization review committee ("3421ff). These criteria include not only medical necessity, but also the availability of out-of-hospital facilities and services which will assume continuity of care. A physician should certify or recertify need for continued hospitalization if the physician finds that the patient could receive treatment in an SNF but no bed is available in the participating SNF. Where the basis for the certification or recertification is the need for continued inpatient care because of the lack of SNF accommodations, the certification or recertification should so state. The physician is expected to continue efforts to place the patient in a participating SNF as soon as the bed becomes available. D. Utilization Review (UR) in Lieu of Separate Recertification Statement --For cases not subject to PPS and for PPS day outlier cases a separate recertification statement is not necessary where the requirements for the second or subsequent recertification are satisfied by review of a stay of extended duration, pursuant to the hospital's UR plan. However, it is necessary to satisfy the certification and recertification content standards. It would be sufficient if records of the UR committee show that consideration was given to the three items mentioned above --the reasons for continued hospitalization (e.g., consideration was given to the need for special or unusual care in cost outlier status under PPS), estimated time the patient will need to remain in the hospital (e.g., the time period during which such special or unusual care would be needed), and plans for posthospital care. 3319. TIMING OF CERTIFICATIONS AND RECERTIFICATIONS. A. Admissions on or after January 1, 1970 for Non-PPS hospitals. --For services furnished to beneficiaries admitted on or after January 1, 1970, the initial certification is required no later than as of the 12th day of hospitalization. A hospital may at its option, provide for the certification to be made earlier, or it may vary the timing of the certification within the 12-day period by diagnostic or clinical categories. The first recertification is required no later than as of the 18th day of hospitalization. Subsequent recertifications must be made at intervals established by the UR committee (on a case-by-case basis), but in no event may the interval between recertifications exceed 30 days. |
MED-MANUAL, 4.1 Bed-Hold Policies for Long Term Care Facilities.Medicare Intermediary Manual (CMS Pub. 13-3) 4.1 Bed-Hold Policies for Long Term Care Facilities. These instructions summarize the policies regarding bed-hold payments made during a resident's absence from a Medicaid nursing facility (NF) or Medicare skilled nursing facility (SNF). Post-admission bed-hold payments are distinguishable from payments for readmission (and thereby permissible) if they represent charges to hold the bed rather than a charge for the act of readmission itself. Similarly, payments made prior to initial admission are distinguishable from post-admission bed-hold payments made during a temporary absence from the facility in that, under the latter, the individual has already established residence in a particular living space within the facility (see 4.F. and 4.1.B.2). A. Medicaid. 1. Law and Regulations. --Under Medicaid payment regulations at 42 CFR 447.40, Federal financial participation is available if a State plan includes provision for bed-hold payments during a recipient's temporary absence from an inpatient facility. (To qualify under this provision, an absence for any purpose other than required hospitalization must be provided for in the patient's plan of care.) However, under 42 CFR 447.40(a)(1), Medicaid can make bed-hold payments only if the State plan provides for them and specifies any limitations on the policy. To satisfy Medicaid's NF requirements for participation in 9(c)(2)(D)(i)-(ii) of the Act, and in 42 CFR 483.12(b)(1)-(2), an NF must tell residents departing for hospitalization or therapeutic leave about the State's bed-hold payment policy. (This information must be in writing and must specify the number of days the State Medicaid program covers, if any, and the NF's policy regarding bed-hold periods.) If a Medicaid eligible resident's absence from the NF exceeds the bed-hold period provided in the State plan, 9(c)(2)(D)(iii) of the Act, and 42 CFR 483.12(b)(3), guarantee the resident readmission to the facility immediately upon the first availability of a bed in a semi-private room in the facility if, at the time of readmission, the resident requires the services provided in the facility. The Medicaid NF requirements for participation in 9(c)(5)(A)(iii) of the Act, and 42 CFR 483.12(d)(3), prohibit a NF from accepting any gift, money, donation, or other consideration as a precondition for a Medicaid eligible individual's admission, expedited admission, or continued stay in the facility. The Medicaid NF requirements for participation in 9(c)(1)(B)(iii)-(iv) of the Act, and 42 CFR 483.10(b)(5)-(6), requires an NF to inform each resident, upon admission and periodically thereafter, of services which the resident can be charged, as well as the amount of the charge. 2. Interpretation. --The Medicaid program does not make payment to reserve a bed before a prospective resident's initial admission to a facility since 42 CFR 447.40 provides authority for Medicaid bed-hold payments only after an individual has been admitted to the facility. Further, under 9(c)(5)(A)(iii) of the Act and 42 CFR 483.12(d)(3), an NF may not accept preadmission bed-hold payments from a Medicaid eligible prospective resident or from any other source on that individual's behalf. The Medicaid prohibition on preadmission payments does not apply to private pay patients. Under Medicaid, the prohibition on accepting preadmission payments (see 42 CFR 483.12(d)(3)) applies only in connection with individuals who are, in fact, Medicaid eligible. If an individual is admitted as a private pay resident, and the Medicaid agency then makes a retroactive eligibility determination that extends back to include the preadmission period, the NF at that point should refund any preadmission payments it had collected with regard to that individual for the period covered by the Medicaid eligibility determination. When a Medicaid eligible individual who has been admitted to the facility takes a temporary leave of absence from the facility, Medicaid can make bed-hold payments under 42 CFR 447.40. However, under 42 CFR 447.40(a)(1), Medicaid can make such payments only if the State plan provides for them and specifies any limitations on the policy. Bed-holds for days of absence in excess of the State's bed-hold limit are considered noncovered services for which the resident may elect to pay. (Under 9(c)(1)(B)(iii) of the Act and 42 CFR 483.10(b)(5)-(6), the facility must inform residents in advance of the period for which Medicaid payments will be made for the holding of a bed, their option to make bed-hold payments if hospitalized or on a therapeutic leave beyond the State's bed-hold period, and the amount of the facility's charge. For these optional payments, the facility should make clear that the resident must affirmatively elect to make them prior to being billed; a facility cannot simply deem a
resident to have opted to make such payments and then automatically bill for them upon the resident's discharge.) Thus, a Medicaid eligible resident whose absence from the facility exceeds the State's bed-hold limit can elect either to: l Ensure the timely availability of a specific bed upon return by making bed-hold payments for any days of absence in excess of the State's payment limit; or l Return upon the first availability of a semi-private bed in the facility in accordance with 9(c)(2)(D) of the Act and 42 CFR 483.12(b)(3). (The first available semi-private bed refers to the first unoccupied bed, in a room shared with another member of the same sex, that is not being held because a resident (regardless of the source of payment) has elected to make payment to hold the bed.) An NF may not impose a minimum bed-hold charge (e.g., a 3-day minimum charge on all bed reservations) because such minimum charges may result in duplication of Medicaid payments for covered services. Further, a bed-hold period should not be appended routinely at the end of each resident's stay without regard to whether the resident's impending departure from the facility will be temporary or permanent; rather, such program payments are appropriate only in those instances where there is a genuine expectation that a particular recipient actually will return to the facility within a reasonable period of time. B. Medicare. 1. Law and Regulations. --The Medicare SNF requirements for participation (see 9 of the Act) contain no provisions corresponding to those of the Medicaid statute in 9(c)(2)(D), and (c)(5)(A)(iii) of the Act. Unlike the Medicaid regulations at 42 CFR 447.40, the Medicare regulations do not include any provisions authorizing the program to make bed-hold payments. The Medicare SNF requirements for participation in 9(c)(1)(B)(iii) of the Act and at 42 CFR 483.10(b)(5)-(6), require a SNF to inform each resident, upon admission and periodically thereafter, of services for which the resident can be charged, as well as the amount of the charge. Under the Medicare provider agreement requirements in 6(a)(2)(B) of the Act and at 42 CFR 489.32(a)(2), a SNF may charge a resident for services in excess of (or more expensive than) covered services only when the services are furnished at the resident's request. The Medicare provider agreement regulations at 42 CFR 489.22 spell out the special provisions appicable to prepayment requirements. While 42 CFR 489.22(d)(1) prohibits Medicare providers (including SNFs) from charging for an agreement to admit or readmit an individual on some specified future date for covered inpatient services, 42 CFR 489.22(a) indicates that a provider may require a prepayment when it is clear upon admission that payment under Part A cannot be made. 2. Interpretation. --Like Medicaid, Medicare does not make bed-hold payments prior to a prospective resident's initial admission to a facility. Further, under the terms of its Medicare provider agreement, a SNF may not accept pre-admission bed-hold payments from or on behalf of a person in return for admitting that person on some specified future date for covered inpatient services. (However, a SNF would not be barred from accepting a pre-admission bed-hold payment from or on behalf of a person who would clearly be denied Part A payment.) Unlike Medicaid, Medicare has no legal authority to make bed-hold payments even after a person's admission to a facility, and the Medicare SNF requirements for participation do not guarantee a return to the first available semi-private bed in the facility. For SNFs, the Medicare prohibition at 42 CFR 489.22(d)(1) applies only to admissions or readmissions for covered inpatient services. According, it would not prohibit pre-admission charges to individuals who are not Medicare eligible, since only Medicare beneficiaries can qualify for program coverage of their care. Thus, the Medicare prohibitions on pre-admission payments do not apply to private pay SNF residents, or to those Medicare beneficiaries who do not meet the requirements for Part A SNF coverage. When temporarily leaving an SNF, a resident can choose to make bed-hold payments to the SNF, as long as the SNF's acceptance of such payment does not represent a prohibited provider practice under 42 CFR 489.22(d)(1). This means that the payment to the SNF is solely for the purpose of reserving the bed during the resident's absence and does not represent a payment for the act of readmission on some future date for covered inpatient services. Under 9(c)(1)(B)(iii) of the Act and 42 CFR 483.10(b)(5)-(6), the facility must inform residents in advance of their option to make bed-hold payments, as well as the amount of the facility's charge. For these optional payments, the facility should make clear that the resident must affirmatively elect to make them prior to being billed; a facility cannot simply deem a resident to have opted to make such payments and then automatically bill for them upon the resident's departure from the facility. As noted previously, 42 CFR 489.22(d)(1) prohibits charging a Medicare beneficiary for admission (or readmission) on some specified future date for covered inpatient services. However, when a Medicare-eligible resident leaves a facility temporarily, it is possible to distinguish between prohibited payments made for the act of admission (or readmission) itself and permissible payments made for holding a resident's bed during the resident's temporary absence. Bed-hold payments are readily distinguishable from payments made prior to initial admission, in that the absent individual has already been admitted to the facility and established residence in a particular living space within it. Similarly, bed-hold payments are distinguishable from payments for readmission, in that the latter compensate the facility merely for agreeing in advance to allow a departing resident to reenter the facility upon return, while bed-hold payments represent remuneration for the privilege of actually maintaining the r
esident's personal effects in the particular living space that the resident has temporarily vacated. One indicator that post-admission payments do, in fact, represent permissible bed-hold charges related to maintaining personal effects in a particular living space (rather than a prohibited charge for the act of readmission itself) would be that the charges are calculated on the basis of a per diem bed-hold payment rate multiplied by however many days the resident is absent, as opposed to assessing the resident a fixed sum at the time of departure from the facility. |
