Jon M. Bradley
Vice Chair, Corpus Christi
Abigail Rios Barrera, M.D.
John A. Cuellar
Manson B. Johnson
Terry Durkin Wilkinson
James R. Hine
October 29, 2001
To: All Medicaid-Certified Nursing Facility and Medicare-Certified Skilled Nursing Facility Providers
Re: Provider Letter 01-39 -- Bed Change Procedures (Replaces Provider Letter #00-26)
The purpose of this letter is to inform providers of revised bed change procedures. The Center for Medicare and Medicaid Services (CMS), formerly known as HCFA, has provided additional guidance regarding the designation of Medicaid distinct parts referenced in Section 3202 of the State Operations Manual. CMS never intended for current Medicaid residents to be relocated to merely comply with this policy.
Definitions For Terms Used In This Letter
Distinct Parts - The term distinct part refers to a portion of a facility that is certified to provide either Medicare or Medicaid services or both. A distinct part must be physically distinguishable from the larger institution and fiscally separate for cost-reporting purposes. The distinct part must consist of all beds within the designated area. The distinct part can be a wing, a separate building, a floor, a hallway or one side of a corridor. Also, the distinct part need not be confined to a single location within the institution or institutional complex's physical plant. It may, for example, consist of several floors or wards in a single building, or floors or wards that are located throughout several different buildings within the same institutional complex.
Fully Participating - An institution is fully participating when the entire institution (all beds within the institution or institutional complex) is certified to participate in either the Medicare or Medicaid program, or both. For example, an institution has four wings that consist of 25 beds each for a total of 100 licensed beds. Three contiguous wings that contain 75 beds are dually participating (i.e., participating in Medicare and Medicaid). The fourth wing, which consists of 25 beds, is only certified to participate in Medicare. Therefore, in this instance, the institution is fully participating for purposes of Medicare (i.e., all 100 beds) and a distinct part for purposes of Medicaid (i.e., 75 beds).
Dually Participating - A bed that is both Medicare (SNF) and Medicaid (NF) certified is a dually participating (SNF/NF) bed.
Medicare Distinct Parts
All facilities in Texas have the option to become fully participating in Medicare, or establish a portion/distinct part of the facility that is Medicare certified. Facilities that elect not to become fully participating in Medicare will be required to adhere to the all-distinct part requirements. (Please refer to the definition of distinct parts.)
Medicaid Distinct Parts
All facilities in Texas do not have the option to become fully participating in Medicaid as they do for Medicare. The number of Medicaid-certified beds in each facility is limited or restricted, due to the Medicaid bed "Allocation, Reallocation and Decertification Requirements" mandated by state legislation in Texas. These requirements are found at 40 TAC §19.2322 of the Department of Human Services (DHS) "Nursing Facility Requirements for Licensure and Medicaid Certification." Because of the Medicaid bed allocation restrictions, many facilities have licensed nursing facility beds that cannot be Medicaid certified. Consequently, the facility cannot elect to become fully Medicaid participating. Therefore, Medicaid distinct parts in Texas nursing facilities are frequently created not based on facility choice, but on mandated bed limitations. Facilities that are not fully participating in Medicaid must comply with the following requirements:
Facilities will identify the location within the facility where they intend to place new Medicaid recipients. They will then locate new Medicaid recipients to that part of the facility, if Medicaid-certified beds are available, and if it is to the resident's benefit. The facility must be able to identify this prospective Medicaid distinct part when requested by DHS staff. The establishment of a prospective Medicaid distinct part will occur over time and with no specific completion date on the part of each nursing facility.
No current Medicaid resident will be required to relocate merely to adhere to the distinct part requirements. When it is to the resident's benefit to move the Medicaid status of an eligible bed to the resident's current location rather than move the Medicaid resident to the vacant Medicaid bed, the bed status should be moved to the resident. Facility residents that become Medicaid-eligible but are not residents within the prospective Medicaid distinct part should be allowed to continue residing in their current location; therefore,
Moving the Medicaid status of a bed to another licensed bed within the nursing facility is permissible and need not be reported to DHS. However, at no time may the number of beds designated by the facility to have Medicaid status exceed the number of Medicaid beds certified.
Moving the Medicaid (NF) status into or out of a dually participating (SNF/NF) bed is also permissible and need not be reported to DHS as long as the conditions of the previous paragraph are met. DHS acknowledges that a by-product of the above procedures in facilities with Medicare and Medicaid distinct parts, is that the number of beds that are dually certified (SNF/NF) will periodically increase or decrease as the NF status of beds is moved into and out of beds in the Medicare distinct part of the facility. Additionally, in facilities that are fully participating in Medicare but also have a Medicaid distinct part, the location of dually certified beds will change as the Medicaid status of beds is periodically moved throughout the Medicare facility. However, the facility must continue to comply with all distinct part requirements related to the Medicare (SNF) distinct part. This includes the prohibition of changing the size or location of the Medicare distinct part without prior approval from DHS. These procedures are described in the following sections.
In all cases, the facility must maintain up-to-date records specifying the location of all licensed beds with Medicare or Medicaid status. The facility must be able to immediately identify the location of all beds with Medicare or Medicaid status on request of DHS staff or staff of any other authorized regulatory agency. The facility must also maintain these same records for Medicaid billing purposes.
Requests for Changes in Bed Size
A change in bed size, for the purpose of this policy, constitutes an increase or decrease in the size of a facility's Medicare and/or Medicaid distinct part. A certified nursing facility may change the size of its distinct part up to two times per cost-reporting year. Facilities may submit only one request for a change in bed size at a time. Two decreases in bed size within the same cost-reporting year will not be permitted. Facilities that undergo a change of ownership or change their cost-reporting year are not exempt from the following bed change procedures:
Requests for changes in bed size must be received in DHS state office 45 calendar days before:
the first day of the facility's cost-reporting year, if the effective date is to be on the first day of the cost reporting year; or
Note: For a facility to change the size of its distinct part up to two times per cost-reporting year, the first request must be received in state office 45 calendar days before the first day of the cost-reporting year; otherwise, only one change in bed size can be made for that year.
There are certain situations which warrant an exception to the policy. Therefore, even if a facility has been approved for changes in bed size in accordance with the policies articulated above, the facility may be granted an additional change in bed size on the basis of one of the following situations:
Life Safety Code (LSC) Requirements -- An exception may be granted if the request is to reduce the size of its distinct part to avoid being out of compliance with LSC requirements (e.g., sprinkler installation). To meet LSC requirements, the proposed bed configuration must be separated from the rest of the facility by a two-hour fire wall, so that there is no danger of a fire spreading from other parts of the facility. In this case, the proposed reduction in size of the distinct part may be established with an effective date requested by the facility. However, the effective date may not be earlier than the date the surveyor has verified that a two-hour fire wall exists. If the reason for the request is to avoid noncompliance with LSC requirements, then the fire authority must perform a full survey.
Elimination of Distinct Part -- An exception may be granted if a facility wants to become fully participating. If this is the case, the facility cannot return to distinct part certification until, at the earliest, the beginning of its next cost reporting year.
Enlargement Through Construction, Purchase, or Lease of Additional Space -- An exception may be granted if the facility requests to increase the size of the distinct part to include space acquired through new construction, purchase or lease (e.g., constructing a new wing, purchasing an adjacent building or leasing a floor in a hospital).
The above bed change requests must be received in state office 45 calendar days before the first day of the facility's next cost-reporting quarter, along with current and proposed floor plans and lists that identify current and proposed bed configurations.
Requests for Changes in Designated Bed Locations
Please apply this section to Medicare distinct parts.
For the purpose of this policy, a change in designated bed locations refers to a change in the location of beds without a change in the size of a facility's distinct part. A facility may request a change in designated bed locations as long as 1) there is no change in the number of beds certified to participate in the Medicare program, and 2) the request is received in state office 30 calendar days before the actual change. In addition, the facility must submit current and proposed floor plans and lists that identify current and proposed bed configurations. This will determine whether the proposed change conforms with rules for distinct part certification or full participation, whichever applies. The request must be approved before the facility makes the change. No changes may be made on a retroactive basis.
A "Request for Bed Changes and Bed Relocations" form is attached for your convenience. Please use this form to list and identify current and proposed bed configurations, and submit it to DHS with all accompanying information. For any bed request to be considered complete, all accompanying information must be received with the request. Incomplete requests will not be processed.
When requesting bed changes, facilities must adhere to notification requirements in 42 CFR 483.10(b)(11)(ii)(A), and residents' rights requirements in 42 CFR 483.10(o). Furthermore, facilities must also adhere to rules on bed allocation, reallocation and decertification in 40 TAC §19.2322 of the "Nursing Facility Requirements for Licensure and Medicaid Certification."
If you have any questions concerning a bed request, please contact DHS Long Term Care-Regulatory, Facility Enrollment Section at (512) 438-2630. For questions concerning bed procedures, contact Bevo Morris in Professional Services at (512) 438-2363.
- Signature on File -
Long Term Care-Regulatory