N.J. Admin. Code § 10:52-1.9

Current through Register Vol. 56, No. 21, November 4, 2024

Section 10:52-1.9 - Administrative days (nursing facility level of care)-general, special (Classification A & B) and private psychiatric hospitals

(a) For a patient who is no longer in need of inpatient acute level of care and who is awaiting placement in a nursing facility, payment shall be made for "administrative days" if the general, special, rehabilitation, or the private psychiatric hospital is able to demonstrate the following:

1. All other possible health insurance benefits have been utilized;

2. Discharge planning was initiated upon admission of the patient to the hospital and was reviewed and updated regularly;

3. Within one working day of identifying a Medicaid/NJ FamilyCare-Plan A beneficiary as being at risk for nursing facility placement, the hospital notified the Medical Assistance Customer Center (MACC), CWA, and the Office of Community Choice Options (OCCO). See N.J.A.C. 10:52-1.11, Preadmission screening for nursing facility placement; and

4. The care and services provided are medically necessary, that is, the attending physician wrote a discharge order from acute care or made a written entry in the medical record that the patient could be transferred to a nursing facility (NF), a Preadmission Screening Evaluation (PAS) confirmed the necessity for nursing facility services and placement could not be made in a NF, as substantiated by documentation of timely and continuous contact (at a minimum, twice a week) with family members, nursing facilities (NFs), and placement agencies.

(b) Upon satisfaction of all the conditions listed under (a)1 through 4 above, payment will be made at the statewide weighted average per diem rate paid to Medicaid participating NFs, as determined on January 1 of each year;

(c)30:4D-6.7 and 6.8 require every nursing facility in the State to reserve a Medicaid beneficiary's bed for up to 10 days when the beneficiary is transferred from the nursing facility to a general or private psychiatric hospital. This requirement is applicable to NJ FamilyCare-Plan A beneficiaries also. If the discharged Medicaid or NJ FamilyCare-Plan A beneficiary is unable to return to the nursing facility before the end of the 10-day period, the discharged beneficiary shall have priority for the next available Medicaid bed in the facility. When the beneficiary is admitted to the hospital under the bed reserve policy, the hospital shall:

1. Involve the NF in the preparation of the hospital's discharge planning;

2. Advise the NF of an anticipated discharge date;

3. Keep the NF informed of the patient's progress, particularly if something unexpected happens which causes a revision to the discharge plan; and

4. Give the NF as much advanced notice as possible to prepare for the return of the patient.

(d) When the 10-day bed reserve is exceeded and no bed is available in the NF from which the beneficiary was transferred, the hospital shall provide the level of NF care determined appropriate by the Department of Human Services' Division of Aging Services (DoAS)-designated professional staff during the Preadmission Screening Evaluation and authorization until such time as a NF bed is available to the Medicaid/NJ FamilyCare-Plan A beneficiary. (See N.J.A.C. 10:52-1.11.)

(e) For the information of hospital staff assisting in the discharge of a patient to an NF, 30:4D-17.3 prohibits, in general, a NF from requiring private pay contracts or donations under certain conditions on behalf of Medicaid beneficiaries. To enforce this prohibition, the law establishes both criminal and civil penalties.

(f)10:5-12.2 of the New Jersey Civil Rights Act prohibits a NF from discriminating against Medicaid eligible persons and beneficiaries of municipal general assistance by denying them admission when the NF's Medicaid occupancy level is below the Statewide occupancy level.

(g) Provisions for reimbursement of administrative days (nursing facility level of care) shall not apply to special hospitals (Classifications A and B).

N.J. Admin. Code § 10:52-1.9

Amended by 50 N.J.R. 1261(a), effective 5/21/2018