DMAS Provider Manual Change Clarified

In last week’s eMemo, we shared with you the fact that the Virginia Department of Medical Assistance Services (DMAS) had issued a memo announcing a nursing facility Provider Manual (PM) update addressing readmission of residents subsequent to hospitalization or therapeutic leave. 

The primary issue addressed in that update focused on the requirement that a nursing facility must allow a resident to return to the next available bed at the time he is ready for discharge from the hospital or return from therapeutic leave.  Our concerns resulted from what we interpreted as new guidance that the nursing facility may not refuse to readmit a resident whose hospitalization or therapeutic leave exceeds the bed-hold period under the State Plan for the following reasons:

• The resident has medical and/or behavioral needs that cannot be met by the nursing facility;
• The resident is judged by a physician to be a danger to self or others; or
• The resident (at the time of readmission) has an outstanding payment to the nursing facility for which he/she is responsible in accordance with Medicaid regulations.

As a result of a meeting earlier today between VHCA staff and DMAS, we are pleased to report to you that DMAS will be revising the previously issued PM update to clarify the changes they are making related to the acceptable exceptions for refusing to readmit a resident.  DMAS has agreed to temporarily rescind the PM update and will be requesting a technical change to the Virginia Administrative Code (VAC) to conform the Code to existing Federal regulations.

This VAC change will eliminate the third exception outlined above as a valid exception.  Facilities must follow the existing requirements that they issue a 30-day discharge notice in cases where there is an unpaid balance due the facility.  Alternatively stated, under no circumstances may a facility refuse readmission solely due to an outstanding financial liability unless they have met the 30-day discharge notice requirements.

Once the VAC language modifications have been made, DMAS will then proceed with the PM changes addressing the removal of the “outstanding balance” exception.  It is anticipated that the VAC change will be processed as a technical amendment and should be completed within the next several months. 

The remaining two exceptions are unchanged and will continue to be available to providers as a basis for denying readmission.  DMAS staff did indicate their intent to emphasize for providers the conditions under which a facility may elect to utilize one of these exceptions.  These exceptions are described more fully in Chapter IV of the Medicaid Nursing Home Manual.