N.M. Code R. § 8.311.5.18

Current through Register Vol. 35, No. 11, June 11, 2024

Section 8.311.5.18 - RESERVE BED DAYS

To allow recipients to visit family or friends for short periods of approved therapeutic leave or to allow trial placement to adjust to a new environment as part of a discharge plan, MAD pays the routine rate to hold or reserve the bed for the recipient's return.

A.Coverage of reserve bed days: Medicaid covers six (6) reserve bed days per calendar year for every swing bed recipient at a high or low nursing facility level without prior approval of the reserve days for any reason other than acute hospitalization, including home visits and acclimation to a new environment. Medicaid covers an additional six (6) days per calendar year with prior approval for visits which help the recipient adjust to a new environment, as part of a discharge plan.

(1) In these cases, the recipient's discharge plan must clearly state objectives including how the home visit or visit to alternative placement relates to discharge implementation.

(2) The prior approval request must include the recipient's name, medicaid number, requested approval dates, and a copy of the discharge plan.

B.Reserve bed days and services not covered: Medicaid does not cover reserve bed days used for transfer to a nursing facility. Medicaid does not pay for ancillary services associated with reserve bed days.

C.Level of care determinations needed: A new level of care determination must be performed if a recipient is gone from the facility for more than three (3) midnights. An abstract must be completed which includes the reason the recipient was absent, outcome of the leave and any other pertinent information.

D.Reimbursement and billing: Reimbursement to a hospital is limited to the rate applicable for the level of care medically necessary for the eligible recipient as determined and certified by MAD. Billing for reserve beds days is based on the nursing census, which runs from midnight to midnight. Under normal circumstances, medicaid pays for the admission day but does not pay for the discharge day. The same principle applies in calculating and billing reserve bed days.

N.M. Code R. § 8.311.5.18

2/1/95; 8.311.5.18 NMAC - Rn, 8 NMAC 4.MAD.723.9, 3/1/12