PURPOSE: This rule establishes a limitation on admissions occurring on Friday or Saturday for inpatient hospital care and on the number of days of preoperative inpatient hospital care which may be paid for by Title XIX Medicaid on behalf of eligible participants. Budgetary limitations necessitate the restriction.

PUBLISHER’S NOTE: The secretary of state has determined that the publication of the entire text of the material which is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive. Therefore, the material which is so incorporated is on file with the agency who filed this rule, and with the Office of the Secretary of State. Any interested person may view this material at either agency’s headquarters or the same will be made available at the Office of the Secretary of State at a cost not to exceed actual cost of copy reproduction. The entire text of the rule is printed here. This note refers only to the incorporated by reference material. (1) For inpatient hospital admissions that have been certified under 13 CSR 70-15.020 and for admissions that do not require certification, the number of days which MO HealthNet will cover for each admission and continuous period of hospitalization shall be limited to those listed in subsection (1)(A), (B), or (C).

1. (A) The number of days indicated as appropriate in accordance with the length-of-stay schedule as set forth in paragraph (1)(A)1. with the exception of those specific diagnoses for which a length-of-stay schedule has been developed by the Medicaid agency as set forth in paragraph (1)(A)2., or as established in 13 CSR 70-15.020 and as stated in paragraph (1)(A)3.

   1. 1. For the diagnosis at the 75th per-

centile average length-of-stay in the 1988 edition of the Length of Stay by Diagnosis for the United States, North Central Region for claims and adjustments processed for payment on or after January 1, 1990.

1. 2. An average length-of-stay schedule,

as developed by the Medicaid agency, for live born infants according to type of birth.

Diagnosis Description, Code and Days

V3000, V3900 Single diagnosis, not operated—three (3) days Single diagnosis, operated—four (4) days Multiple diagnosis, not operated—four (4) days Multiple diagnosis, operated—ten (10) days V3001, V3101, V3201, V3301, V3401, V3501, V3601, V3701, V3901 Single diagnosis, not operated—three (3) days Single diagnosis, operated—three (3) days Multiple diagnosis, not operated—five (5) days Multiple diagnosis, operated—fifteen (15) days V3100, V3200, V3300, V3400, V3500, V3600, V3700 Single diagnosis, not operated—four (4) days Single diagnosis, operated—four (4) days Multiple diagnosis, not operated—seven

1. (7) days Multiple diagnosis, operated—twelve (12) days

V301, V311, V321, V331, V341, V351, V361, V371, V391 Single diagnosis, not operated—two (2) days Single diagnosis, operated—two (2) days Multiple diagnosis, not operated—four (4) days 13 CSR 70-15

Multiple diagnosis, operated—fifteen (15) days

1. 3. Continued stay reviews will be per-

formed for alcohol and drug abuse detoxification services to determine the days that are medically necessary and appropriate for inpatient hospital care.

1. (B) The number of days certified as medically necessary by the medical review agent.
2. (C) The number of days billed as covered service by the provider.

1. (2) In administering this limitation, the counting of days which may be allowable under the provider’s internal Hospital Utilization Review Committee’s certified medically necessary days always shall be from the beginning date of admission for a continuous period of hospitalization. The counting of days which may be Medicaid allowable also will be from the beginning date of admission unless conditions described in subsection (2)(A), (B), or (C) apply.

   1. (A) If the participant’s beginning date of eligibility is later than the date of admission, the counting of days which may be allowable will be from the beginning eligibility date.
   2. (B) If the participant has exhausted Title XVIII inpatient benefits, the counting of days which may be allowable will be from the date following the date on which the Title XVIII benefits are exhausted.
   3. (C) If the date of admission is not certified under 13 CSR 70-15.020 as medically necessary, the counting of days which may be allowable for reimbursement will be from the date approved for admission by the medical review agent.
2. (3) Reimbursement shall be made at the applicable per diem rate in effect as of the initial date of admission and for only allowable days during which the participant is eligible.
3. (4) The state agency will conduct reviews, approve and specify any additional days which may be allowed beyond the number of days already paid, or may review recommendations submitted by a medical consultant licensed to practice medicine in Missouri. At its discretion, the state may concur with a recommendation and approve all days for payment, disagree and not pay any days or modify and pay some portion of the days recommended.
4. (5) Reimbursement for any additional days approved for acute care will be made at the hospital’s per diem rate in effect on the date of admission. If a hospital has an established intermediate care facility/skilled nursing facility (ICF/SNF) or SNF-only Medicaid rate for providing nursing home services in a distinct part setting, reimbursement for any additional days approved for only ICF or SNF level of care provided in the inpatient hospital setting will be made at the hospital’s ICF/SNF or SNF-only rate. If a hospital does not have an established ICF/SNF or SNF- only Medicaid rate for providing nursing home services in a distinct part setting, reimbursement for any additional days approved for only ICF or SNF level of care will be made at the hospital’s per diem rate in effect at the time of admission. No additional days will be approved and no Medicaid payments will be made on behalf of any participant who it is determined received inpatient hospital care when s/he did not need either inpatient hospital services or nursing home ICF or SNF services.

AUTHORITY: sections 208.152, 208.153, and 208.201, RSMo Supp. 2013.* This rule was previously filed as 13 CSR 40-81.051. Emergency rule filed April 7, 1981, effective April 20, 1981, expired July 10, 1981. Original rule filed April 7, 1981, effective July 11, 1981. Emergency amendment filed July 15, 1981, effective Aug. 1, 1981, expired Oct. 10, 1981. Emergency amendment filed Aug. 21, 1981, effective Sept. 1, 1981, expired Dec. 10, 1981. Amended: Filed July 15, 1981, effective Oct. 11, 1981. Emergency amendment filed Nov. 20, 1981, effective Dec. 1, 1981, expired March 10, 1982. Amended: Filed Aug. 21, 1981, effective Dec. 11, 1981. Amended: Filed Nov. 20, 1981, effective March 11, 1982. Amended: Filed April 14, 1982, effective July 11, 1982. Emergency amendment filed Nov. 24, 1982, effective Dec. 4, 1982, expired March 10, 1983. Amended: Filed Nov. 24, 1982, effective March 11, 1983. Emergency amendment filed April 8, 1983, effective April 18, 1983, expired July 10, 1983. Amended: Filed April 8, 1983, effective July 11, 1983. Emergency amendment filed Dec. 21, 1983, effective Jan. 1, 1984, expired April 11, 1984. Emergency amendment filed March 14, 1984, effective March 28, 1984, expired June 10, 1984. Amended: Filed March 14, 1984, effective June 11, 1984. Amended: Filed Oct. 15, 1984, effective Feb. 11, 1985. Amended: Filed Jan. 15, 1985, effective April 11, 1985. Amended: Filed April 2, 1986, effective Sept. 1, 1986. Amended: Filed June 17, 1986, effective Sept. 1, 1986. Emergency amendment filed Sept. 17, 1986, effective Sept. 27, 1986, expired Jan. 25, 1987. Amended: Filed Aug. 1, 1986, effective Oct. 11, 1986. Amended: Filed Nov. 14, 1986, effective Jan. 30, 1987. Amended: Filed May 4, 1987, effective July 23, 1987. Amended: Filed Jan. 5, 1988, effective March 25, 1988. Amended: Filed April 4, 1988, effective July 1, 1988. Emergency amendment filed Dec. 1, 1989, effective Jan. 1, 1990, expired April 29, 1990. Amended: Filed Dec. 1, 1989, effective Feb. 25, 1990. Amended: Filed Dec. 4, 1989, effective Feb. 25, 1990. Emergency amendment filed June 18, 1991, effective July 15, 1991, expired Oct. 28, 1991. Amended: Filed March 18, 1991, effective Aug. 30, 1991. Emergency amendment filed June 20, 1991, effective July 1, 1991, expired Oct. 28, 1991. Emergency amendment filed Oct. 15, 1991, effective Oct. 29, 1991, expired Feb. 6, 1992. Emergency amendment filed Oct. 15, 1991, effective Oct. 29, 1991, expired Feb. 6, 1992. Amended: Filed June 18, 1991, effective Oct. 31, 1991. Amended: Filed June 18, 1991, effective Oct. 31, 1991. Amended: Filed June 15, 2005, effective Dec. 30, 2005. Amended: Filed July 16, 2007, effective Feb. 29, 2008. Amended: Filed Sept. 16, 2013, effective March 30, 2014. *Original authority: 208.152, RSMo 1967, amended 1969, 1971, 1972, 1973, 1975, 1977, 1978, 1981, 1986, 1988, 1990, 1992, 1993, 2004, 2005, 2007, 2011, 2013; 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007, 2012; and 208.201, RSMo 1987, amended 2007.