Section 1187.176. Criteria for the approval of bed requests other than bed transfer requests

(a) The Department may approve a bed request, other than a bed transfer request, only if the following are satisfied:

(1) The bed request contains the information required under § 1187.172(a) (relating to contents and submission of bed requests).

(2) The additional MA-certified nursing facility beds are needed in the primary service area or the county in which the subject facility is located to maintain or improve MA recipients’ access to medically necessary nursing facility services based on any of the following:

(i) The existing MA-certified bed capacity in the primary service area or the county in which the subject facility is or will be located is insufficient to assure that MA recipients have access to medically necessary nursing facility services.

(ii) Systemic barriers prevent MA recipients from accessing the existing MA-certified bed capacity in the primary service area or the county in which the subject facility is or will be located.

(iii) The applicant is proposing to admit and serve MA recipients who require specialized medical services in the subject facility and MA recipients do not have access to the specialized medical services in the existing MA-certified bed capacity in the primary service area or the county in which the subject facility is or will be located.

(3) The legal entity agrees, in a form acceptable to the Department, to the following:

(i) The subject facility will admit and serve MA day-one recipients.

(ii) The subject facility will maintain an MA occupancy rate that equals or exceeds the average MA occupancy rate of MA nursing facilities in the county in which the subject facility is or will be located or, in the case of a subject facility that is proposing to offer specialized medical services, the MA occupancy rate as may be agreed to by the Department.

(iii) The construction and operation of the new or additional beds will be economically and financially feasible without the receipt of MA fixed property capital component payments, and it is not entitled to MA capital component payments for fixed property related to the new or additional beds.

(4) None of the circumstances specified in § 1187.172(a)(4) applies.

(b) In determining whether a need for additional MA-certified beds exists under subsection (a), the following will apply:

(1) MA-certified bed capacity will be deemed sufficient if the average annual overall occupancy rates of providers in the primary service area and county in which the subject facility is or will be located is 95% or less, based on the most recent MA cost report data submitted by those providers.

(2) If the average annual overall occupancy rates of providers in the primary service area or county in which the subject facility is located exceeds 95%, based on the most recent MA cost report data submitted by those providers, the Department will consider the following information in assessing whether a need for additional MA-certified beds exits:

(i) The total number of MA-certified nursing facility beds in the primary service area.

(ii) The total number of licensed nursing facility beds in the primary service area.

(iii) The annual overall occupancy rates of providers in the primary service area based on the most recent MA cost report data submitted by those providers.

(iv) The annual actual bed days in the primary service area for the most recent 3-year period including the most recent cost report period, as submitted by nursing facility providers in the primary service area.

(3) No systemic barrier that prevents MA recipients from accessing MA-certified bed capacity will be deemed to exist if the average MA occupancy rate and the average MA day-one admission rate of providers in the primary service area and county in which the subject facility is or will be located are above the Statewide average rates or within one percentage point below the Statewide rates.

(c) The Department may deny a bed request even if the conditions specified in subsection (a) are satisfied if the Department determines one of the following:

(1) Approval of the request would negatively affect the Department’s goal to rebalance the Commonwealth’s publicly-funded long-term living system to create a fuller array of service options for MA recipients.

(2) There are alternatives to the bed request, such as an increase in home and community-based services, that would be less costly, more efficient or more appropriate in assuring that long-term living care and services will be provided under the MA Program in a manner consistent with applicable Federal and State law.

Notation

Cross References

This section cited in 55 Pa. Code § 1187.172 (relating to contents andn submission of bed requests).