R414-502-5. Criteria for Intensive Skilled Care

A nursing facility must demonstrate that the applicant meets the following criteria before the Department may authorize Medicaid reimbursement for intensive skilled care:

(1) The applicant meets the need for skilled services provided by a nursing facility certified pursuant to 42 CFR 409.20 through 409.35, or a swing bed hospital approved by the Centers for Medicare and Medicaid Services to furnish skilled nursing facility care in the Medicare program.

(2) The following routine skilled care does not qualify as intensive skilled care in making a determination under Section R414-502-5:

(a) Skilled nursing services described in 42 CFR 409.33(b);

(b) Skilled rehabilitation services described in 42 CFR 409.33(c);

(c) Routine monitoring of medical gases after a therapy regimen;

(d) Routine enteral tube and gastronomy feedings; and

(e) Routine isolation room and techniques.

(3) The applicant has exhausted Medicare benefits or has been denied by Medicare for other reasons other than level of care requirements.

(4) The applicant requires and receives at least five additional hours of direct licensed professional nursing care daily, including a combination of specialized care and services, and assessment by a registered nurse and 24-hour observation.

(5) The applicant meets criteria for intensive skilled care if the attending physician makes any one of the following determinations:

(a) There is no reasonable expectation that the applicant will benefit further from any care and services available in an acute care hospital that are not available in a nursing facility; or

(b) The applicant's condition requires physician follow-up at the nursing facility at least once every 30 days;

(c) An interdisciplinary team may indicate a therapeutic leave of absence from the nursing facility is appropriate either to facilitate discharge planning or to enhance the applicant's medical, social, educational, and habilitation potential; and

(d) Except in extraordinary circumstances, the applicant has been hospitalized immediately before admission to the nursing facility.

(6) The applicant has continuously required skilled care, either through Medicare or Medicaid, since admission to the nursing facility.

(7) If the attending physician has written and signed progress notes at the time of each physician visit that reflect the current medical condition of the applicant.

(8) An applicant who was previously approved for intensive skilled care and later downgraded to a lower care level may return to intensive skilled care instead of being hospitalized in an acute care setting if :

(a) A complication occurs that involves the condition for which the applicant was originally approved for intensive skilled care; and

(b) It has been less than 30 days since the termination of the previous intensive skilled care.