Title 55--PUBLIC WELFARE DEPARTMENT OF PUBLIC WELFARE [55 PA. CODE CH. 6000] Procedures for Funding Reserved Hospital and Leave Days Under 2176 Waiver [26 Pa.B. 1829] Purpose
The purpose of this statement of policy is to issue revised procedures for funding reserved hospital and leave days under the 2176 waiver.
Background
Procedures on Federal and State reimbursement for days in which individuals receiving waiver services are hospitalized or on a leave status were first issued on August 29, 1985, and revised on May 31, 1988. These procedures were consistent with rules established for MA funded long-term care and were approved by the Health Care Financing Administration (HCFA) as part of the Department's first 5-year waiver renewal which ended June 30, 1995.
In a March 24, 1995, letter to the National Association of State Directors of Developmental Disabilities Services, Inc., the HCFA explained that states are prohibited from making specific therapeutic leave payments for Medicaid-reimbursable home and community-based services. The reason given for this prohibition is that Federal financial participation for therapeutic leave days applies to institutional care, not home and community services.
HCFA regional staff are being instructed to give states a reasonable period of time to bring their program policies into compliance with a reimbursement system where the cost of leave days should be factored into provider rates. HCFA plans to make no attempt to recover past leave days payments for noncomplying states which make timely revisions in their procedures. In coming into compliance with new Federal policy, the Department has been able to maintain its current policy regarding hospital leave and has only needed to change the portion of the policy related to therapeutic leave.
This revised statement of policy is intended to ensure continued Federal financial participation in the cost of maintaining waiver services for individuals who are absent from services for a reasonable period of time due to hospitalization or other legitimate reason. Implementation of this policy should also continue to encourage family visits, excursions with friends or groups, and other forms of leave which support the individual's choices and participation in home and community life.
Discussion
A reserved hospital day is a 24-hour period of inpatient hospitalization during which the provider of service does not provide any waiver funded services for the individual but does reserve a place in the service or program for the individual when he returns from the hospital stay.
A reserved leave day is a 24-hour period in which the individual is absent from a waiver funded service when each of the following criteria are met:
(1) The provider reserves a place in the service or program for the individual when he returns from leave.
(2) The provider assumes fixed staffing or other service costs while the individual is on leave.
(3) The provider does not claim additional Federal and State financial participation for services rendered to someone who takes the place of the individual on leave.
FEATHER O. HOUSTOUN,
SecretaryFiscal Note: 14-BUL-042. No fiscal impact; (8) recommends adoption.
Annex A TITLE 55. PUBLIC WELFARE PART VIII. MENTAL RETARDATION MANUAL Subpart A. STATEMENTS OF POLICY CHAPTER 6000. STATEMENTS OF POLICY Subchapter P. PROCEDURES FOR FUNDING RESERVED HOSPITAL AND LEAVE DAYS UNDER 2176 WAIVER Sec.
6000.841. Procedures for funding reserved hospital and leave days under 2176 waiver. § 6000.841. Procedures for funding reserved hospital and leave days under 2176 waiver.
(a) The Department will participate in the cost of a reserved hospital or leave day when:
(1) The cost of the reserved hospital or leave day is established as part of the provider's rate pursuant to a vacancy factor in the calculation of the rate. The vacancy factor, in effect, adjusts the provider's rate to account for anticipated costs for reserving the service during the individual's hospitalization or leave. The vacancy factor should be based on historic leave or hospitalization rates, or both, and the characteristics of individuals receiving services. Rates and vacancy factors will continue to be approved by the county mental health and mental retardation program in accordance with its fiscal responsibilities under Chapter 4300 (relating to county mental health and mental retardation fiscal manual).
(2) The cost of the reserved day is reconciled to actual allowable costs and reported to the county mental health/mental retardation program through the provider's annual audit. The county then reports these costs on the appropriate annual income and expenditure report to the Department for waiver eligible services.
(3) The provider is able to maintain a cost effective service. Extremely high rates of leave can jeopardize service effectiveness and reasonableness of costs. The Department expects that the county mental health/mental retardation program will closely monitor vacancy rates in all waiver funded services to assure that providers are rendering services at the frequency and duration that individuals need. The regional program offices will also review service utilization as part of their ongoing waiver reviews to assure cost effectiveness.
(b) A reserved hospital or leave day is a vacancy and as such is not billable or reportable as a day or unit of waiver services to the county mental health/mental retardation program or to the Department.
[Pa.B. Doc. No. 96-630. Filed for public inspection April 19, 1996, 9:00 a.m.]
