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Benefits by Service: Inpatient Hospital, Nursing Facility and Intermediate Care Facility Services In Institutions for Mental Diseases, age 65 and older (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: 3

No: 42

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

Alabama
Yes			Hosp leave days not covered, 6 therapeutic leave days/quarter limited to 3 days/leave up to 24 days/year	Prospective cost based per diem	CN
Alaska
Yes		Initially to determine LOC, initially and periodically for LOS	Hosp leave days not covered, 5 therapeutic leave days/year	Prospective cost based per diem	CN
Arizona
Yes			12 hosp leave days/year, 9 therapeutic leave days/year	Acute Care program - capitated payment through contractor, ALTCS program - prospective acuity-based per diem or negotiated rate for heavy care residents and certain facilities	CN & MN
Arkansas
No
California
Yes				Prospective cost based per diem	CN & MN
Colorado
Yes				Prospective cost based per diem	CN
Connecticut
Yes			15 hosp leave days/hospitalization, 21 therapeutic leave days/year, facility must have fewer than 3 vacancies to be paid	Prospective cost based per diem or cost based payment	CN & MN
Delaware
Yes			18 therapeutic leave days/year	Prospective cost based per diem	CN
District of Columbia
Yes			18 days hosp or therapeutic leave/year	Prospective cost based per diem	CN & MN
Florida
Yes			15 hosp leave days/hospitalization, 30 therapeutic leave days/year	Prospective cost based per diem	CN
Georgia
No
Hawaii
No
Idaho
Yes			Hosp leave days not covered, 3 therapeutic leave days/home visit up to 15 days/year, facility must have fewer than 5 or 5% of its licensed beds vacant to be paid	Prospective cost based per diem with limits, leave days paid at 75% of facility's rate	CN
Illinois
Yes		Yes	LOS in private hospitals limited by State's Utilization Review authority, nursing facility residents limited to 7 therapeutic leave days/absence up to 10/month with no coverage of hosp leave days and facility must have 93% occupancy rate to be paid	Per diem based on certified cost for state-operated facilities, prospective cost based per diem for all other facilities, nursing facilities paid for leave days at 75% of facility's rate	CN & MN
Indiana
Yes			Services limited to hospital settings, 60 therapeutic leave days/year	Prospective cost based per diem, leave days paid at 50% of facility's rate	CN
Iowa
Yes			10 hosp leave days/hospitalization, 18 therapeutic leave days/year	Prospective cost based per diem, leave days paid at 75% of facility's rate	CN
Kansas
Yes	$48/hospital admission		10 hosp leave days/acute care hospitalization, 21 hosp leave days/psychiatric hospitalization and 21 therapeutic leave days/year - leave days apply to nursing facilities for mental health only	Cost based payment for state-operated hospitals, prospective payment/discharge using DRG for other hospitals, prospective cost based per diem with leave days paid at 67% of facility's rate for nursing facilities	CN & MN
Kentucky
Yes			Leave days must be medically necessary and included in care plan	Prospective cost based per diem, cost based payment for ancillary services	C & D - See state-specific FN
Louisiana
Yes		Admission and LOS certification	Limited to inpatient hospital settings	Prospective cost based per diem	CN & MN
Maine
Yes			10 hosp leave days/year, 36 therapeutic leave days/year	Cost based payment using percentage of charge	CN & MN
Maryland
Yes			Nursing facility and intermediate care facility residents limited to 15 hosp leave days/hospitalization, 18 therapeutic leave days/year	Prospective cost set by rate commission	CN & MN
Massachusetts
Yes				Prospective cost based per diem	CN & MN
Michigan
Yes				Prospective cost based per diem for public facilities, private facility reimbursement determined by contracted PIHPs	CN & MN
Minnesota
Yes				Prospective payment per discharge using DRG	A - See state-specific FN
Mississippi
No
Missouri
Yes			12 therapeutic leave days/6 months	Prospective cost based per diem	CN & MN
Montana
Yes		Therapeutic leave exceeding 3 days	Hosp leave days not covered, 24 therapeutic leave days/year	Prospective cost based per diem, up to Medicare limits	A - See state-specific FN
Nebraska
Yes		Preadmission certification		Prospective cost based per diem	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	Cost based payment	CN
New Hampshire
Yes		Admission to nursing facility		Prospective cost based per diem	CN & MN
New Jersey
Yes			10 hosp leave days/hospitalization, 24 therapeutic leave days/year	Prospective cost based per diem	CN
New Mexico
Yes		Admission		Cost based payment with limits	CN
New York
Yes				Prospective cost based per diem, some services may be paid on a fee for service basis	CN & MN
North Carolina
Yes		Admission	Hosp leave days not covered, 15 consecutive therapeutic leave days up to 60 days/year, 3 administrative leave days to facilitate transfer to less restrictive setting	Prospective cost based per diem	CN & MN
North Dakota
Yes			28 therapeutic leave days/year	Cost based per diem, with limits	CN & MN
Ohio
Yes			Services limited to hospital settings, leave days not covered	Prospective payment/discharge using DRG	CN
Oklahoma
Yes				Prospective cost based per diem	CN
Oregon
Yes			Leave days not covered	Prospective cost based per diem	A - See state-specific FN
Pennsylvania
Yes			15 hosp leave days/hospitalization, 30 therapeutic leave days/year	Per diem using case-mix payment system, 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 cost based per diem	CN & MN - see state-specific FN
South Carolina
Yes			10 hosp leave days/hospitalization, 9 consecutive therapeutic leave days up to 18 days/year	Prospective cost based per diem	CN
South Dakota
Yes			5 hosp leave days/hospitalization, 15 consecutive therapeutic leave days	Prospective cost based per diem	CN
Tennessee
Yes	B1 - $100/hospital admission, B2 - $200/hospital admission	Admission to nursing facilities	B - Care in nursing facilities not covered	Hospital payment rate established by MCC, 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	A & B - See state-specific FN
Texas
No
Utah
Yes			Hosp leave days not covered, 12 therapeutic leave days/year	Prospective cost based per diem	A - See state-specific FN
Vermont
Yes				Prospective payment/discharge using DRG	A - See state-specific FN
Virginia
Yes		Admission	Hosp leave days not covered, 7 consecutive therapeutic leave days up to 18 days/year	Prospective per diem or cost based payment	CN
Washington
Yes			Hosp leave days not covered, 18 therapeutic leave days/year	Prospective cost based per diem	CN & MN
West Virginia
No
Wisconsin
Yes	$3/day up to $75/admission if hospital IMD		15 hosp leave days/hospitalization, unlimited therapeutic leave days, facility must have 95% occupancy or fewer than 9 vacant beds to be paid	Prospective payment/discharge using DRG for private hospital IMDs, prospective cost based per diem for nursing facility and state-operated IMDs	CN & MN
Wyoming
Yes			14 leave days of any type/year	Private facilities paid contracted rates, public facilities paid prospective cost based per diem	CN
American Samoa
No
Guam
No
Northern Mariana Islands
No
Puerto Rico
No
Virgin Islands
No

Definition/Notes: Link to Inpatient Hospital, Nursing Facility and Intermediate Care Facility Services In Institutions for Mental Diseases, age 65 and older Footnote


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