CurrentAlabama MedicaidPolicy N/A

Chapter 46 — Swing Beds

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Governs Alabama Medicaid participation, enrollment, reimbursement, level-of-care, services, billing, admission review, and patient agreements for hospital swing bed programs; applies to hospitals seeking or holding swing bed approval under Alabama Medicaid.

Policy Summary

PayerAlabama Medicaid

PolicyChapter 46 — Swing Beds

Policy CodePolicy N/A

Change TypeNo material change

Effective DateDec 17, 2013

Last ReviewDec 17, 2013

Next Review DateN/A

Key ActionProviders must submit a written enrollment request with proof of licensure, Medicare swing bed certification, and certificate of need; approved providers receive a provider agreement to sign within 30 days.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12rules/sections

12/17/2013effective

12 monthsagreement validity

3 daysqualifying acute stay

Coverage criteria for swing bed services

Policy Summary

PayerAlabama Medicaid

PolicyChapter 46 — Swing Beds

Policy CodePolicy N/A

Change TypeNo material change

Effective DateDec 17, 2013

Last ReviewDec 17, 2013

Next Review DateN/A

SourceLink

On This Page

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CurrentAlabama MedicaidPolicy N/A

Chapter 46 — Swing Beds

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Sign up for all Alabama Medicaid policy alerts

Know when Alabama Medicaid releases new policies or updates existing guidance.

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Policy Summary

PayerAlabama Medicaid

PolicyChapter 46 — Swing Beds

Policy CodePolicy N/A

Change TypeNo material change

Effective DateDec 17, 2013

Last ReviewDec 17, 2013

Next Review DateN/A

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12rules/sections

12/17/2013effective

12 monthsagreement validity

3 daysqualifying acute stay

Coverage criteria for swing bed services

Policy Summary

PayerAlabama Medicaid

PolicyChapter 46 — Swing Beds

Policy CodePolicy N/A

Change TypeNo material change

Effective DateDec 17, 2013

Last ReviewDec 17, 2013

Next Review DateN/A

SourceLink

On This Page

Coverage criteria for swing bed services

Covered when ALL of the following are met:

Recipient must meet SNF medical and financial eligibility requirements identical to SNF admissions; skilled-level need must be present on a daily basis.

The skilled services provided must be ones that, on a practical basis, can only be provided on an inpatient basis (services that do not ordinarily require skilled care may be considered skilled when a special medical condition requires skilled performance or supervision).

Services are covered only when ordered by a physician.

Swing bed admissions that are not covered by Medicare because they fail to meet Medicare medical criteria are also non-covered by Medicaid and cannot be reimbursed as straight Medicaid services.

Covered services include

Nursing care provided by or under the supervision of a registered nurse.
Bed and board in a semi-private room (private accommodations allowable only when medically required or semi-private rooms unavailable).
Over-the-counter drugs routinely used in patient care (e.g., acetaminophen, aspirin, antacids, antidiarrheals, stool softeners).
Personal services and facility supplies ordinarily furnished for patient comfort and cleanliness.
Nursing and treatment supplies as ordered by the physician (examples: needles, syringes, catheters, drainage bags, dressings, IV administration sets, common IV fluids).

Duration: Services are unlimited in duration provided the recipient continues to meet SNF level of care and all eligibility criteria (including financial eligibility).

Reimbursement, billing, and rate references

Reimbursement and billing rulesmixedCovered

Per diem reimbursement at the average rate per patient day paid by Medicaid to SNF/ICF combination facilities for routine services furnished during the previous calendar year; no year-end cost settlement.

Reimbursement cap reference

Per diem reimbursement basisPer diem paid at the average rate per patient day paid by Medicaid to SNF/ICF combination facilities for routine services furnished during the previous calendar year (no year-end cost settlement)

Ancillary services billingAncillary services (lab, x-ray, prescription drugs) are billed and reimbursed separately under the appropriate program areas (e.g., outpatient hospital services for x-rays)

Per diem inclusionsPer diem rate includes routine supplies and over-the-counter medications such as acetaminophen, aspirin, antacids, antidiarrheals, laxatives, and stool softeners

Medicare Part A coinsuranceMedicaid may pay Medicare Part A coinsurance for dually eligible or QMB recipients who qualify under Medicare skilled-level rules; payable amount not greater than the average nursing facility rate

Enrollment, agreements, admissions, and utilization review

Documentation Required

Submit enrollment packet and sign provider agreement

Providers wishing to enroll must submit a written request to Medicaid and include proof of current hospital licensure (if not already on file), proof of current Medicare swing bed certification (if not already on file), and proof of a certificate of need (CON) if not on file. Each request is reviewed for completeness and accuracy prior to approval; approved providers will be issued a provider agreement that must be signed and returned to Medicaid within 30 days of the date mailed. Provider agreements are valid for no more than 12 calendar months, and the effective date of enrollment cannot be earlier than the date of the enrollment application.

Submit written enrollment request to Medicaid
Include: current hospital licensure, Medicare swing bed certification, and CON (if not on file)
Provider agreement mailed upon approval — sign and return within 30 days
Provider agreements valid ≤ 12 calendar months
Effective enrollment date cannot precede application date

Prior Authorization

Obtain admission review and perform required recertifications

Admission for Medicaid-covered swing bed care requires review by the Medicaid Medical and Quality Review Unit (or its designee) to verify necessity and that a physician certified the need for swing bed care on the date of admission using Form 199; the Unit (or designee) will certify level of care and may issue medical approvals. Continued-stay recertifications are required at 30, 60, and 90 days after admission and then every 60 days thereafter, with the physician stating “I certify” and specifying the patient requires skilled care. The admission packet (fully completed Form 199 with physician-certified documentation) must be sent to the Medical and Quality Review Unit or designee within 60 days from the date Medicaid coverage is sought.

Medical and Quality Review Unit (or designee) performs admission review and certifies level of care using Form 199
If not approved, a Medical Director will review and approve/deny eligibility
Admission packet (completed Form 199 and supporting physician-certified documentation) must be submitted within 60 days
Continued-stay recertifications: 30, 60, 90 days after admission, then every 60 days; physician must state “I certify” and specify need for skilled care
A 3-day qualifying acute hospital stay is required prior to swing bed admission for reimbursement and must be within the same period of illness

Key definitions

Swing bed (definition)

DefinitionHospital beds that can be used for either skilled nursing facility (SNF) or hospital acute care levels of care on an as‑needed basis when the hospital has obtained swing bed approval from the Department of Health and Human Services

Provider eligibility criteriaHospital must have fewer than 100 beds (excluding newborn and intensive care beds) and be located in a rural area as defined by the Census Bureau

Certification and CONHospital must be Medicare certified as a swing bed provider and have a certificate of need for swing beds

Regulatory complianceHospital must be substantially in compliance with specified SNF conditions of participation and execute an Alabama Medicaid Agency provider agreement

Level of care (SNF)

SNF level-of-care requirementRecipient must require SNF level of care on a daily basis; skilled services must be ones that, on a practical basis, can only be provided on an inpatient basis

Special medical conditionsA condition not ordinarily requiring skilled care may be considered skilled if, due to a special medical condition, the service must be performed by or supervised by skilled nursing or rehabilitation personnel

Restoration potential not decisiveRestoration potential is not the deciding factor; skilled services may be needed to prevent further deterioration or preserve current capabilities

Medicare non‑coverage effectSwing bed admissions not covered by Medicare because they do not meet medical criteria are also non‑covered by Medicaid and cannot be reimbursed as straight Medicaid services