PURPOSE: This rule outlines the coverage of nursing facility costs to reserve a bed in a nursing facility during an absence from the facility due to a hospital admission of three days or less and the limitations related to that coverage.

1. (1) Payment to a nursing facility (NF) for hospital leave days is authorized for days in which a Medicaid recipient is absent from the NF due to admission to a hospital for services which cannot be performed on an outpatient basis, subject to the following:

   1. (A) The nursing facility in which the Medicaid resident resides is licensed under Chapter 198, RSMo;
   2. (B) The NF is in compliance with all federal and state certification standards;
   3. (C) The occupancy rate of the NF is at or above ninety-seven point zero percent (97.0%), rounded to four (4) decimal places, of Medicaid certified licensed beds, for the quarter prior to the first day of services provided based on the census for that quarter provided from the Division of Aging to the Division of Medical Services;
   4. (D) The Medicaid recipient is admitted to a hospital for a medical condition, which cannot be treated on an outpatient basis, with a total stay of three (3) days or less; and
   5. (E) The hospital provides a discharge plan for the recipient which includes returning to the facility requesting the hospital leave days.
2. (2) The payment for hospital leave days shall only be provided for qualified hospital stays of three (3) days or less. A qualified hospital stay is one in which the medical condition cannot be treated on an outpatient basis.
3. (3) The hospital leave days billed by the nursing facility shall be held in suspense until the nursing home bill, hospital bill and quarterly census has been received by the Division of Medical Services so appropriate payment can be determined.
4. (4) Payment for authorized hospital leave days shall be at the per-diem rate for the respective provider.
5. (5) For each day that Medicaid reimburses a nursing facility, pursuant to this subsection, the Medicaid recipient shall be ineligible for reimbursement to nursing facilities for two otherwise available temporary leave of absence days as described in 13 CSR 70- 10.010(5)(D). The total hospital leave days and temporary leave of absence days shall not exceed the limits for the periods defined in 13 CSR 70-10.010(5)(D).

AUTHORITY: sections 208.153, RSMo Supp. 1991, 208.159, RSMo 1986 and 208.201, RSMo Supp. 1987.* Emergency rule filed Dec. 17, 1993, effective Dec. 27, 1993, expired April 25, 1994. Emergency rule filed April 15, 1994, effective May 1, 1994, expired Aug. 28, 1994. Original rule filed Nov. 2, 1993, effective June 6, 1994. *Original authority: 208.153, RSMo 1967, amended 1973, 1989, 1990, 1991; 208.159, RSMo 1979; and 208.201, RSMo 1987.