Medicaid Benefits: Online Database

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Benefits by Service: Nursing Facility Services, other than in an Institution for Mental Diseases (October 2008) Definition/Notes

Note: Totals include 50 states and D.C.

"Benefits Covered" Totals

"Benefits Not Covered" Totals

Is the benefit covered?

Is there a co-payment requirement?

Yes: 0

No: 51

Is the Benefit Covered?	Copayment Requirement	Prior Approval Requirement	Coverage Limitations	Reimbursement Methodology	Populations Covered

Alabama
Yes			4 hosp leave days/hospitalization, 6 therapeutic leave days/quarter limited to 3 days/leave up to 24 days/year	Prospective per diem based on cost and facility class	CN
Alaska
Yes		Initially to determine LOC, initially and periodically for LOS	Hosp leave days not covered, unlimited therapeutic leave days/year up to 5 days consecutively	Prospective per diem based on cost	CN
Arizona
Yes		Admission	Acute Care program members limited to 90 days for convalescence/year - see state-specific FN, ALTCS members have no LOS limit but are limited to 12 hosp leave days/year and 9 therapeutic leave days/year	Prospective per diem based on resident class/acuity, negotiated rates for heavy care residents and certain facilities	CN & MN
Arkansas
Yes			5 hosp leave days/hospitalization, facility must have 85% occupancy rate to be paid, unlimited therapeutic leave days up to 14 days consecutively	Prospective cost based per diem	CN
California
Yes		Specialized rehab services, higher payment for complex cases, e.g., ventilator dependent	30 treatment absences in 120 days for rehab therapy, 7 hosp leave days/hospitalization, 18 therapeutic leave days/year	Standard per diem by facility size, location and level of care; state may negotiate all-inclusive rates with certain facilities	CN & MN
Colorado
Yes			Hosp leave days not covered, 42 therapeutic leave days/year	Prospective per diem based on cost, acuity adjusted, with limits	CN
Connecticut
Yes			15 hosp leave days/hospitalization, 21 therapeutic leave days/year, facility must have fewer than 3 vacancies to be paid	Prospective per diem based on cost, with limits	CN & MN
Delaware
Yes			7 hosp leave days/month, 18 therapeutic leave days/year	Prospective per diem based on cost and acuity, up to Medicare limits	CN
District of Columbia
Yes			18 days hosp or therapeutic leave/year	Prospective per diem based on cost, with efficiency incentives, up to Medicare limits	CN & MN
Florida
Yes			8 hosp leave days/hospitalization, 16 therapeutic leave days/year	Prospective per diem by facility size and location, occupancy adjusted, with higher rates for heavy care residents, payment for leave days requires 95% occupancy rate in prior quarter	CN
Georgia
Yes		For LOC determination upon admission	Limited to facilities dually certified for Medicare, 7 hosp leave days/hospitalization, 8 therapeutic leave days/year	Prospective cost based per diem with limits, leave days paid 95% of per diem	CN
Hawaii
Yes			12 hosp or therapeutic leave days/year, up to 3 consecutive days	Prospective cost based per diem	CN & MN
Idaho
Yes		Admission	Services limited to Enhanced Plan and Medicare/Medicaid Coordinated Plan, hosp leave days not covered, 3 therapeutic leave days per home visit covered up to 15 days/year - See state-specific FN	Prospective per diem with limits, leave days paid at 75% of allowable costs	CN
Illinois
Yes			Hosp leave days not covered, 7 therapeutic leave days/absence up to 10/month, facility must have 93% occupancy rate to be paid	Prospective per diem based on cost and facility class with occupancy adjustments and efficiency incentives for private facilities with leave days paid at 75% of facility's rate, certain government-operated facilities paid 94% of Medicare rate and other county-operated facilities paid per diem based on certified cost	CN & MN
Indiana
Yes		For LOC determination upon admission, therapies, specified prescription drugs	15 consecutive hosp leave days/hosp, 30 therapeutic leave days/year	Prospective per diem based on cost, leave days paid at 50% of facility's rate if 90% occupancy requirement met	CN
Iowa
Yes			10 hosp leave days/hospitalization, 18 therapeutic leave days/year	Prospective per diem based on resident acuity, leave days paid at 42% of facility's rate	CN
Kansas
Yes		Admission of a child under age 16	10 hosp leave days/acute care hospitalization, 18 hosp leave days/psychiatric hospitalization	Prospective per diem based on cost, leave days paid at 67% of facility's rate	CN & MN
Kentucky
Yes			14 hosp leave days/hospitalization up to 14 days/year, 10 therapeutic leave days/year	Prospective per diem by resident class/acuity, ancillary services paid fee for service, leave days paid at 75% of facility's rate if occupancy 95% or more and 50% of rate if lower	D - See state-specific FN
Louisiana
Yes		For LOC determination upon admission	7 hosp leave days/hospitalization, 15 therapeutic leave days/year	Private facilities paid prospective acuity adjusted per diem, cost based per diem up to Medicare limits for public facilities	CN & MN
Maine
Yes			10 hosp leave days/year, 36 therapeutic leave days/year	Prospective per diem based on cost, up to Medicare limits	CN & MN
Maryland
Yes			15 hosp leave days/hospitalization, 18 therapeutic leave days/year	Cost based reimbursement	CN & MN
Massachusetts
Yes			10 hosp leave days/hospitalization, 10 therapeutic leave days/year	Prospective per diem based on case mix adjusted standard payments, higher rates for heavy care residents, cost based payment to pediatric facilities if costs exceed industry benchmarks	CN & MN
Michigan
Yes		Therapies and customized med equipment	10 hosp leave days/year, 18 therapeutic leave days/year	Prospective per diem based on cost with limits, reduced per diem paid for hospital leave days and only if 98% occupancy requirement met	CN & MN
Minnesota
Yes			18 hosp leave days/hospitalization, 36 therapeutic leave days/year, residents in facilities licensed to serve physically disabled permitted 72 therapeutic leave days/year	Prospective per diem with annual legislated rate adjustment, acuity and quality adjusted, leave days paid at 60% of facility's rate	A - See state-specific FN
Mississippi
Yes			Unlimited hosp leave days/year but no more than 15 consecutive hospital leave days, 52 therapeutic leave days/year plus Christmas and Thanksgiving as well as the day prior and after each	Prospective per diem based on cost and facility class, acuity adjusted	CN
Missouri
Yes			12 therapeutic leave days/6 months	Prospective per diem based on cost	CN & MN
Montana
Yes		Therapeutic leave exceeding 3 days	Hosp leave days not covered, 24 therapeutic leave days/year	Prospective per diem using statewide price limits, acuity adjusted	A & B - See state-specific FN
Nebraska
Yes		Admission of beneficiaries over age 64	15 hosp leave days/hospitalization, 18 therapeutic leave days/year	Prospective cost based per diem, with limits	CN & MN
Nevada
Yes			Hosp leave days not covered, therapeutic leave limited to rehabilitative and pre-discharge transitional home and community visits up to 24 days/year	Prospective price-based per diem	CN
New Hampshire
Yes			30 reserve bed days/year if established criteria met	Prospective per diem based on cost, acuity adjusted	CN & MN
New Jersey
Yes			10 hosp leave days/hospitalization, 24 therapeutic leave days/year if in plan of care	Prospective per diem based on cost with incentives for high occupancy, hosp leave days paid at 50% of per diem rate	CN
New Mexico
Yes		Admission	6 leave days/year of any type with additional 6 days allowed if approved	Prospective per diem based on cost, with limits, leave days paid at 50% of per diem rate	CN
New York
Yes				Prospective per diem based on cost using peer groups and acuity adjusted	CN & MN
North Carolina
Yes		Admission	Hosp leave days not covered, 15 consecutive therapeutic leave days up to 60 days/year	Prospective per diem based on cost, with limits	CN & MN
North Dakota
Yes			15 hosp leave days/hospitalization, 24 therapeutic leave days/year	Prospective per diem based on cost, acuity adjusted, with limits	CN & MN
Ohio
Yes			30 hosp or therapeutic leave days/year	Prospective per diem with limits and acuity adjustment, leave days paid one-half of per diem rate	CN
Oklahoma
Yes			5 hosp leave days/year, 7 therapeutic leave days/year	Prospective per diem based on cost and facility class, leave days paid 50% of per diem	CN
Oregon
Yes			Leave days not covered	Prospective per diem based on cost	A - See state-specific FN
Pennsylvania
Yes			15 hosp leave days/hospitalization, 30 therapeutic leave days/year	Per diem using case-mix payment systemic, hosp leave days paid at 1/3 of nursing facility's rate and therapeutic leave days paid at full rate	CN & MN
Rhode Island
Yes			Leave days not covered	Prospective per diem based on cost, with efficiency incentives and occupancy adjustments	CN & MN - see state-specific FN
South Carolina
Yes			10 hosp leave days/hospitalization, 9 consecutive therapeutic leave days up to 18 days/year, additional days allowed for approved rehab programs or transition to community placement	Prospective per diem based on cost using peer groups and assuming 96% occupancy, low volume facilities paid statewide average rate	CN
South Dakota
Yes		For LOC determination upon admission	5 hosp leave days/hospitalization, 15 consecutive therapeutic leave days if in plan of care	Prospective per diem based on cost, with limits	CN
Tennessee
Yes		Admission	10 leave days of any type/year but limited to level 1 facilities	Nursing facility-specific prospective cost based per diem for level 1 and lower of facility's cost, charge or 65th percentile per diem cost of similar facilities for level 2, reimbursement for hospital leave days only if 85% occupancy requirement met	A - See state-specific FN
Texas
Yes		Admission	3 consecutive therapeutic leave days	Prospective per diem based on cost and acuity adjusted, higher rates for heavy care residents	CN & MN
Utah
Yes			Hosp leave days not covered, 12 therapeutic leave days/year	Prospective per diem based on cost with efficiency incentives, negotiated rates for heavy care residents	A - See state-specific FN
Vermont
Yes			B - 30 days/stay up to 60 days/year, A & B - 6 hosp leave days/hospitalization and 24 therapeutic leave days/year	Prospective per diem	A & B - See state-specific FN
Virginia
Yes		Admission	18 therapeutic leave days/year	Prospective per diem based on cost and acuity adjusted	CN & MN
Washington
Yes			Hosp leave days not covered, 18 therapeutic leave days/year	Prospective per diem based on cost using peer groups, with efficiency incentives and assuming 85% occupancy	CN & MN
West Virginia
Yes		Yes	12 hosp leave days/year, 6 therapeutic leave days/year	Prospective per diem based on cost assuming 90% occupancy, payment for leave days dependent on occupancy rate	A & B
Wisconsin
Yes		Specialized med equipment	15 hosp leave days/hospitalization, unlimited therapeutic leave days, facility must have at least 95% occupancy rate or fewer than 9 vacant beds to be paid	Prospective per diem based on cost using peer groups with some settlement, leave days paid at 85% of facility's rate	CN & MN
Wyoming
Yes		Admission of a child under 21	14 leave days of any type/year	Prospective per diem based on cost with efficiency incentives, higher rates for heavy care residents	CN
American Samoa
Yes			Post hospital extended care only		See territory-specific FN
Guam
Yes			180 days/year	Negotiated rate/service	CN
Northern Mariana Islands
Yes			Post hospital extended care only		CN & MN - See territory-specific FN
Puerto Rico
No - see territory-specific FN
Virgin Islands
Yes				Cost based per diem, up to Medicare limits	CN

Definition/Notes: Link to Nursing Facility Services, other than in an Institution for Mental Diseases Footnote


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