16 Del. Admin. Code § 20000-20650

Current through Register Vol. 28, No. 7, January 1, 2025

Section 20000-20650 - Temporary Absence from a Long-Term Care Facility

42 CFR § 447.40

Payment will be made for reserving beds in long-term care (LTC) facilities for Medicaid recipients during their temporary absence for the following purposes:

1 Temporary Absence from a Long-Term Care Facility for Acute Hospitalization

2 Temporary Absence from a Long-Term Care Facility for Reasons Other Than Hospitalization

7 DE Reg. 781 (12/1/03)

20650.1Temporary Absence from a Long-Term Care Facility for Acute Hospitalization

20650.1.1 Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID)

If a recipient is hospitalized for a short period of time and is expected to return to the facility, payment to the facility may continue for a period of not more than fourteen (14) days provided the ICF/IID agrees to hold the bed for the resident. Medicaid reimbursement is available for no more than fourteen (14) days within any thirty-day period. The thirty-day count begins with the first day of hospitalization. If payments are suspended because recipient remains hospitalized more than fourteen (14) days and the thirty-day count expires, a new thirty-day count starts with readmission to the ICF/IID. In other words DMMA will not pay fourteen (14) days out of every thirty (30) days for people who remain in the hospital for weeks at a time.

20650.1.2 Other Long-Term Care Facilities

If a recipient is hospitalized for a short period of time and is expected to return to the facility, payment to the facility may continue for a period of not more than seven (7) days provided the LTC facility agrees to hold the bed for the resident. Medicaid reimbursement is available for no more than seven (7) days within any thirty-day period. The thirty-day count begins with the first day of hospitalization. If payments are suspended because recipient remains hospitalized more than seven (7) days and the thirty-day count expires, a new thirty-day count starts with readmission to the LTC facility. In other words DMMA will not pay seven (7) days out of every thirty (30) days for people who remain in the hospital for weeks at a time.

20650.2Temporary Absence from a Long-Term Care Facility for Reasons Other Than Hospitalization

20650.2.1 A recipient may be absent from a long-term care facility for reasons other than hospitalization for a period of eighteen (18) days per year without interruption of payment to the long-term care facility, as long as such absences are provided for in the recipient's plan of care.

20650.2.2 If a recipient's physical condition is being negatively impacted by his or her emotional need to be in a family setting, prior approval may be obtained for a waiver of the eighteen-day leave of absence limitation (for other than acute care hospitalization) from the Title XIX Medical Consultant in order to allow the patient more time to visit with his or her family.

To obtain approval, a written request must be submitted by the long-term care facility to the Long-Term Care Coordinator and must include:

20650.2.2.1 Reason for the request;

20650.2.2.2 Medical summary;

20650.2.2.3 Statement from the LTC facility's medical director regarding the medical necessity of the patient being absent from the LTC facility in excess of eighteen (18) days per year;

20650.2.2.4 Anticipated frequency of absence; and

20650.2.2.5 Number of days the recipient was absent from the LTC facility during the previous six month period. If the approval is given, the eighteen-day restriction will be waived for six (6) months from the date of approval. Any request for a waiver after the six-month limit must be resubmitted and approved for payments to be continued.

16 Del. Admin. Code § 20000-20650

19 DE Reg. 1092( 6/1/2016) (final)