Our next “Ftag of the Week” on the CMSCG Blog is F620 Admissions Policy, which is part of the Admission, Transfer, and Discharge regulatory group. A facility’s Admission agreement is generally reviewed with the facility’s counsel, and due to the varying State Medicaid plan requirements, what needs to be included in an admissions policy can differ. As such, in this post, we will cover what’s required by the Centers for Medicare & Medicaid Services (CMS) related to admissions, but readers should recognize that their individual State and other laws may be more stringent.
All nursing homes are required to develop and implement a resident admissions policy. The admissions policy needs to comply with transfer and discharge regulatory requirements, as well as ensure that certain rights or preconditions for admission are prohibited. There are also specific details that must be disclosed to residents/ potential residents, and the facility needs to have a documented process in place regarding how it discloses this information to those individuals.
When you read through Appendix PP and the Interpretive Guidance (IG) for F620 Admissions Policy, you may think that it could be better to more appropriate to place this information in the Resident Rights regulatory group, because this regulation sets out a list of dos and donts for providers during the admission process to ensure a prospective resident’s rights are not violated in the process. In this case of the admissions, facilities are prohibited from requesting or requiring a resident/ potential resident to:
- Waive his/her rights, including their rights to Medicare or Medicaid
- Provide written or oral assurance that the resident is not eligible for – and will not apply for – Medicare or Medicaid benefits
- Waive potential facility liability for losses of resident personal property
The Interpretive Guidance specifies that both direct and indirect requests regarding waiving the above rights are not allowed. Specifically, a “direct request” would be when a facility requires a resident to sign an admissions document where the resident specifically agrees to not apply for Medicare or Medicaid. An “indirect request” would be a situation where the facility requires a resident to pay private pay rates for a certain length of time before he/she can use Medicaid as the payment source. The intent is to protect residents from requiring private pay when the residents may be eligible for other payment sources.
While nursing homes are also prohibited from requesting or requiring a third-party payment guarantee to the facility as a condition of admission, expedited admission or continued stay in the facility, a facility is allowed to request one thing from the resident representative. If a resident representative has legal access to a resident’s income or resources available to pay for care, the facility can request that the person sign a contract to provide the facility with payment from the resident’s income or resources. The contract cannot make the resident representative personally financially liable for payment – it is only allowed when the representative can legally access the resident’s income or financial resources to pay for his/her care.
Facilities are also permitted to charge a deposit fee or require a promissory note from an individual whose stay is not covered by Medicaid. If the facility charges a deposit fee that is refundable, then the facility’s surety bond needs to cover the amount of the deposit.
For Residents Eligible for Medicaid
Providers are permitted to charge Medicaid-eligible residents for items and services if the resident has requested and received those items/services are they are not specified as included in the “nursing facility services” language of the State Medicaid plan. The facility must provide appropriate notice to the resident regarding the availability and associated cost of the services. The resident/ potential resident may not be required to use and pay for these services as a condition for admission or continuing stay at the facility.
When a Medicaid Application is Pending:
- A facility can charge an applicant or resident for services while his/her Medicaid application is pending. The charge can be either a deposit prior to admission or a payment after admission.
- Depending on the State, the resident’s Medicaid eligibility may be made retroactive up to 3 months before the application if the resident would have been eligible in any of those months.
The facility is required to accept the amounts determined by the State as payment in full for all dates where the resident was at the nursing facility and Medicaid-eligible. If the facility charged the resident for services between the date that the resident became Medicaid-eligible and the date that the notice of eligibility was received, that facility would be required to refund any payments made by the residents for the same time period minus the State’s determination of the resident’s cost-share during that time. Sounds confusing, right? That’s why the regulatory guidance also states that facilities are required to display written information about how to apply for Medicaid and use Medicaid benefits as well as how to receive refunds for previous payments. Make sure you have that information posted for your residents, and in a manner that they can understand.
Don’t forget – Per F622 Transfer and Discharge Requirements, a resident cannot be discharged for non-payment while his/her Medicaid eligibility is still pending.
Facility Responsibility for Loss of Personal Property
As noted in an earlier section of this post, facilities cannot request or require a resident or potential new admission to waive the facility’s responsibility if his/her personal property becomes lost. Likewise, residents cannot be restricted from using personal property because the facility’s policy is to “safeguard” those items in a manner which basically makes them inaccessible to the residents. So, if a provider implemented a policy that electronic devices must be stored in a locked area with limited personnel access, otherwise the facility is not liable for the loss, then this is not permissible. Instead, what CMS notes in the IG is that the requirement is not to make facilities automatically liable when a resident’s personal property is lost, but instead have reasonable policies in place to reduce the risk of loss.
The IG notes that these policies could include processes for:
- Documenting high-value personal property brought in by residents, such as money, valuables and resident medical/assistive devices
- Working with residents/ representatives to ensure the safety of resident money while also ensuring availability of money if the resident needs it
- How the facility works with the resident/ representative to secure high-value items, including the resident’s medical and/or assistive devices.
The admissions policy must include information that must be disclosed to residents or potential residents. As such, providers are required to disclose and provide information to potential residents prior to the time of admission, and to residents, any special characteristics or service limitations that the facility has. This information is intended to help prospective residents understand what the facility can provide to them and understand that in certain circumstances, the facility may not be capable of handling a specific care need.
The facility is also required to disclose its physical configuration if it has a composite distinct part, including which locations comprise that part. The facility’s policy for room changes between these locations must also be included in the admission agreement.
What’s a composite distinct part, you ask? Well, if you have to ask, you probably don’t need to worry about that information being in your admissions agreement, but just in case, here are some definitions:
“Campus” – This is considered the physical area that is immediately adjacent to the provider’s main building(s), other areas and structures that are not contiguous to the main buildings but are located within 250 yards of those buildings.
“Distinct Part” – A part of a nursing facility that is physically distinguishable from the larger institution/ complex that it is housed on.
”Composite Distinct Part” – Distinct part of two or more non-contiguous components that are not located within the same campus.
During survey, if a concern related to the facility’s admission procedures arises, the surveyor will review the facility’s admissions packet to see if the required information is included, as well as interview residents/ representatives to determine if there were any pre-conditions or requirements for admission.