Medicaid Benefits: Nursing Facility Services, Other Than in an Institution for Mental Disease, Age 21+
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2018
| Location | Benefit Covered | Coverage Code | Copayment Required? | Limits on Services | Prior Approval Required | Reimbursement Methodology |
|---|---|---|---|---|---|---|
| United States | Yes - 51 | 2018 data limited to CN | Yes - 12 | Yes - 23 | Included in "Limits on Services" for 2018 | Not included in 2018 survey |
| Alabama | Yes - Mandatory | CN | Patient Liability for Nursing Facility Residents | No | - | - |
| Alaska | Yes - Mandatory | CN | Depends on income | No | - | - |
| Arizona | Yes - Mandatory | CN | No | 90 days per contract year only in lieu of hospitalization. | - | - |
| Arkansas | Yes - Mandatory | CN | NR | NR | - | - |
| California | Yes - Mandatory | CN | No | No | - | - |
| Colorado | Yes - Mandatory | CN | No | NR | - | - |
| Connecticut | Yes - Mandatory | CN | No | No | - | - |
| Delaware | Yes - Mandatory | CN | No | Up to 30 days for Diamond State Health Plan | - | - |
| District of Columbia | Yes - Mandatory | CN | No | Requires a Level of Care determination, and annual UR review. | - | - |
| Florida | Yes - Mandatory | CN | No | No | - | - |
| Georgia | Yes - Mandatory | CN | NR | NR | - | - |
| Hawaii | Yes - Mandatory | CN | No | No | - | - |
| Idaho | Yes - Mandatory | CN | No | No | - | - |
| Illinois | Yes - Mandatory | CN | NR | NR | - | - |
| Indiana | Yes - Mandatory | CN | No | Prior authorization for LOC determination upon admission, therapies, specified prescription drugs, leave days not covered. | - | - |
| Iowa | Yes - Mandatory | CN | NR | NR | - | - |
| Kansas | Yes - Mandatory | CN | No | Reserve days are limited to 10 per confinement. | - | - |
| Kentucky | Yes - Mandatory | CN | Yes - Not Specified | Must meet patient status - level of care requirements | - | - |
| Louisiana | Yes - Mandatory | CN | Each Medicaid resident is required to pay a Patient Liability Amount each month. The amount is based on the resident's income. | NFs are reimbursed 10% of their per diem rate for residents on leave from the facility. This reimbursement is limited to 7 consecutive hospital days and 15 annual home leave days. | - | - |
| Maine | Yes - Mandatory | CN | No | Limits imposed on number of hospital leave and therapeutic leave days per year | - | - |
| Maryland | Yes - Mandatory | CN | No | Level of care pre authorization | - | - |
| Massachusetts | Yes - Mandatory | CN | No | No | - | - |
| Michigan | Yes - Mandatory | CN | No | Nursing Facility Level of Care | - | - |
| Minnesota | Yes - Mandatory | CN | No | No | - | - |
| Mississippi | Yes - Mandatory | CN | No | Home/therapeutic leave limited to 42 days per fiscal year, in addition to: Christmas day, the day before Christmas, the day after Christmas, Thanksgiving day, the day before Thanksgiving day,and the day after Thanksgiving day, Hospital leave-15 days of inpatient hospital leave per each absence for continuous acute care during an inpatient hospital stay. | - | - |
| Missouri | Yes - Mandatory | CN | No | No | - | - |
| Montana | Yes - Mandatory | CN | No | Residents of a nursing facility must meet level of care requirements. | - | - |
| Nebraska | Yes - Mandatory | CN | Yes - Not Specified | No | - | - |
| Nevada | Yes - Mandatory | CN | Patient Liability | Level of Care required | - | - |
| New Hampshire | Yes - Mandatory | CN | No | NR | - | - |
| New Jersey | Yes - Mandatory | CN | Calculated pay liability for ABD | No | - | - |
| New Mexico | Yes - Mandatory | CN | The cost sharing is in the form of a recipient liability, which is based on the recipient's financial ability to pay some amount toward their own nursing home care. | No | - | - |
| New York | Yes - Mandatory | CN | NR | NR | - | - |
| North Carolina | Yes - Mandatory | CN | Amt. varies based on income. | No | - | - |
| North Dakota | Yes - Mandatory | CN | No | 15 leave days for hospitalization per year 24 therapeutic leave days per year | - | - |
| Ohio | Yes - Mandatory | CN | No | Nursing Facility Level of Care; 30 be-hold/leave days per calendar year. | - | - |
| Oklahoma | Yes - Mandatory | CN | No | Medical necessity and level of care criteria must be met | - | - |
| Oregon | Yes - Mandatory | CN | No | Screening and assessment to determine level of care needs. | - | - |
| Pennsylvania | Yes - Mandatory | CN | No | No | - | - |
| Rhode Island | Yes - Mandatory | CN | No | No | - | - |
| South Carolina | Yes - Mandatory | CN | NR | NR | - | - |
| South Dakota | Yes - Mandatory | CN | NR | LOC determination upon admission. 5 hospital leave days/hospitalization, 15 consecutive therapeutic leave days if in plan of care, therapy services limited to those provided through the facility | - | - |
| Tennessee | Yes - Mandatory | CN | No | No | - | - |
| Texas | Yes - Mandatory | CN | No | There is no limitation of days; however, individuals must meet medical necessity for at least 184 consecutive days to obtain permanent medical necessity. | - | - |
| Utah | Yes - Mandatory | CN | No | Medical necessity and level of care criteria must be met | - | - |
| Vermont | Yes - Mandatory | CN | No | No | - | - |
| Virginia | Yes - Mandatory | CN | NR | No | - | - |
| Washington | Yes - Mandatory | CN | No | Prior authorization required | - | - |
| West Virginia | Yes - Mandatory | CN | Financial eligibility evaluation completed monthly | No | - | - |
| Wisconsin | Yes - Mandatory | CN | Cost share amounts vary based on Medicaid eligibility, however, long-term skilled nursing facility residents who are not veterans are generally limited to a personal needs allowance of $45 per month. | A small number of services require prior approval to receive enhanced reimbursement rates. Bedhold days limited to 15 hospital leave days per hospitalization. Therapeutic bedhold leave is unlimited. A facility must have >94% occupancy in the prior calendar month to bill for bedhold. | - | - |
| Wyoming | Yes - Mandatory | CN | Patient contribution determined by Eligibility Unit and applied to nursing home and swing bed claims; amount differs by resident. | LT101 and PASRR requirements must be met by all Wyoming Medicaid NH and swing bed residents. | - | - |
2012
| Location | Benefit Covered | Coverage Code | Copayment Required? | Limit on services days | Prior Approval Required | Reimbursement Methodology |
|---|---|---|---|---|---|---|
| United States | Yes - 54 No - 2 | Yes - 0 No - 54 | ||||
| Alabama | Yes | CN | 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, full per diem paid for leave days | ||
| Alaska | Yes | CN | Hosp leave days not covered, unlimited therapeutic leave days/year up to 12 days consecutively | Initially to determine LOC, initially and periodically for LOS | Prospective per diem based on cost, full per diem paid for leave days | |
| American Samoa | No | |||||
| Arizona | Yes | CN & MN | Acute Care program members limited to 90 days for convalescence/year, ALTCS members have no LOS limit but are limited to 12 hosp leave days/year and 9 therapeutic leave days/year | Admission | Prospective per diem based on resident class/acuity, negotiated rates for heavy care residents and certain facilities, full per diem rate paid for leave days | |
| Arkansas | Yes | CN | 5 hosp leave days/hospitalization, facility must have 85% occupancy rate to be paid, unlimited therapeutic leave days up to 14 days consecutively; home-style facility regulations incorporated into policy | Prospective cost based per diem, full per diem rate paid for leave days | ||
| California | Yes | CN & MN | 30 days for mentally disabled persons or persons in mental health therapeutic programs, 73 days for developmentally disabled, 7 hosp leave days/hospitalization, 18 therapeutic leave days/year | Yes, including specialized rehab services and higher payment for complex cases, e.g., ventilator dependent | Standard per diem by facility size, location and level of care; state may negotiate all-inclusive rates with certain facilities; reduced per diem rates paid for leave days with reduction value set annually | |
| Colorado | Yes | CN | Hosp leave days not covered, 42 therapeutic leave days/year | Prospective per diem based on cost, acuity adjusted, with limits, full per diem paid for leave days | ||
| Connecticut | Yes | CN & MN | 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, full per diem paid for leave days | ||
| Delaware | Yes | CN | 7 hosp leave days/month, 18 therapeutic leave days/year | Prospective per diem based on cost and acuity, up to Medicare limits, full per diem paid for leave days | ||
| District of Columbia | Yes | CN & MN | 18 days hosp or therapeutic leave/year | Prospective per diem based on cost, with efficiency incentives, up to Medicare limits, full per diem paid for leave days | ||
| Florida | Yes | CN | 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, full per diem paid for leave days | ||
| Georgia | Yes | CN | Limited to facilities dually certified for Medicare, 7 hosp leave days/hospitalization, 8 therapeutic leave days/year | For LOC determination upon admission | Prospective cost based per diem with limits, leave days paid 75% of per diem | |
| Guam | Yes | CN | 180 days/year | Medicare interim per diem rate | ||
| Hawaii | Yes | CN & MN | 12 hosp or therapeutic leave days/year with up to 3 consecutive days | Prospective cost based per diem, full per diem paid for leave days | ||
| Idaho | Yes | CN | 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 | Admission | Prospective per diem with limits, leave days paid at 75% of allowable costs | |
| Illinois | Yes | CN & MN | Yes | Prospective per diem based on cost and facility class with occupancy adjustments and efficiency incentives for private facilities, certain government-operated facilities paid 94% of Medicare rate and other county-operated facilities paid per diem based on certified cost, facilities paid special rates for serving ventilator-dependent residents | ||
| Indiana | Yes | CN | Leave days not covered | For LOC determination upon admission, therapies, specified prescription drugs | Prospective per diem based on cost | |
| Iowa | Yes | CN | Prospective per diem based on resident acuity | |||
| Kansas | Yes | CN & MN | 10 hosp leave days/acute care hospitalization, 18 hosp leave days/psychiatric hospitalization | Admission of a child under age 16 | Prospective per diem based on cost, leave days paid at 67% of facility's rate | |
| Kentucky | Yes | C - See state-specific FN | Benefit limited to short-term acute conditions, 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 reported at 95% or more and 50% of rate if lower or not reported | ||
| Louisiana | Yes | CN & MN | 7 hosp leave days/hospitalization, 15 therapeutic leave days/year | For LOC determination upon admission | Private facilities paid prospective acuity adjusted per diem, cost based per diem up to Medicare limits for state facilities, leave days paid percentage of per diem dependent upon occupancy rate | |
| Maine | Yes | CN & MN | 4 hosp leave days/year, 1 therapeutic leave day/year | Prospective per diem based on cost, up to Medicare limits, full per diem paid for leave days | ||
| Maryland | Yes | CN & MN | 18 therapeutic leave days/year | Level of care determination | Cost based reimbursement, non-nursing component of per diem rate paid for leave days | |
| Massachusetts | Yes | CN & MN | 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, leave days paid approximately 50% of median rate | ||
| Michigan | Yes | CN & MN | 10 hosp leave days/hosp, 18 therapeutic leave days/year | Therapies and customized med equipment | Prospective per diem based on cost with limits, reduced per diem paid for leave days if 98% occupancy requirement met | |
| Minnesota | Yes | A - See state-specific FN | 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 | ||
| Mississippi | Yes | CN | 30 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, full per diem paid for leave days | ||
| Missouri | Yes | CN | 3 hospital leave days/hospitalization if specified criteria met, 12 therapeutic leave days/6 months | Prospective per diem based on cost, full per diem paid for leave days | ||
| Montana | Yes | A & B - See state-specific FN | Hosp leave days covered if facility is full with a waiting list and resident expected to return, 24 therapeutic leave days/year | Therapeutic leave exceeding 3 days | Prospective per diem using statewide price limits, acuity adjusted; full per diem paid for leave days | |
| Nebraska | Yes | CN & MN | 15 hosp leave days/hospitalization, 18 therapeutic leave days/year | Admission of beneficiaries over age 64 | Prospective cost based per diem adjusted for acuity, with limits; leave days paid at HCBS assisted living rate | |
| Nevada | Yes | CN | 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, full per diem paid for leave days | ||
| New Hampshire | Yes | CN & MN | Hosp leave days not covered, therapeutic leave limited to 30 days/year if established criteria met | Prospective per diem based on cost, acuity adjusted, full per diem paid for leave days | ||
| New Jersey | Yes | CN | 10 hosp leave days/hospitalization, 24 therapeutic leave days/year | Prospective per diem based on cost with incentives for high occupancy; payment to facilities for bed holds during leave days is not covered | ||
| New Mexico | Yes | CN | 6 leave days/year of any type with additional 6 days allowed if approved; A - benefit limited to post-acute treatment for rehab | Admission | Prospective per diem based on cost, with limits, leave days paid at 50% of per diem rate | |
| New York | Yes | CN & MN | 15 hosp leave days/hosp; 18 therapeutic leave days/year; facility must have 95% or higher occupancy rate to be paid | Prospective per diem based on cost using peer groups and acuity adjusted, leave days paid a reduced per diem rate | ||
| North Carolina | Yes | CN & MN | Hosp leave days not covered, 15 consecutive therapeutic leave days up to 60 days/year | Admission review required to assure appropriate level of care | Prospective per diem based on cost, with limits; quarterly adjustment based on facility case mix index, full per diem rate paid for leave days | |
| North Dakota | Yes | CN & MN | 15 hosp leave days/hospitalization, 24 therapeutic leave days/year | Prospective per diem based on cost, acuity adjusted, with limits; per diem paid for leave days based on lowest acuity level | ||
| Northern Mariana Islands | Yes | CN & MN - See territory-specific FN | Post hospital extended care only | |||
| Ohio | Yes | CN | 30 hosp or therapeutic leave days/year, leave days not covered for residents receiving hospice care | Prospective per diem with limits and acuity adjustment, high occupancy facilities paid 50% of per diem rate for leave days and others paid 18% of per diem rate | ||
| Oklahoma | Yes | CN | 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 | ||
| Oregon | Yes | A - See state-specific FN | Leave days not covered | Prospective per diem based on cost | ||
| Pennsylvania | Yes | CN & MN | 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 | ||
| Puerto Rico | No - see territory-specific FN | |||||
| Rhode Island | Yes | See state-specific FN | Leave days not covered | Prospective per diem based on cost, acuity adjusted | ||
| South Carolina | Yes | CN | 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, full per diem paid for leave days | ||
| South Dakota | Yes | CN | 5 hosp leave days/hospitalization, 15 consecutive therapeutic leave days if in plan of care | For LOC determination upon admission | Prospective per diem based on cost, with limits, full per diem paid for leave days | |
| Tennessee | Yes | C - See state-specific FN | 10 leave days of any type/year but limited to level 1 facilities | Admission | Reimbursement rates established and paid by managed care contractors | |
| Texas | Yes | CN | 3 consecutive therapeutic leave days | Admission | Prospective per diem based on cost and acuity adjusted, higher rates for heavy care residents, hospice room and board paid 95% of per diem rate | |
| Utah | Yes | A - See state-specific FN | 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, full per diem paid for leave days | ||
| Vermont | Yes | A & B - See state-specific FN | B - 30 days/stay up to 60 days/year and only covered under PC Plus; A & B - 6 hosp leave days/hospitalization and 24 therapeutic leave days/year | Prospective per diem, full per diem paid for leave days if occupancy criteria met | ||
| U.S. Virgin Islands | Yes | CN | Cost based per diem, up to Medicare limits | |||
| Virginia | Yes | CN & MN | Hosp leave days not covered, 18 therapeutic leave days/year | Admission | Prospective per diem based on cost and acuity adjusted, full per diem paid for leave days | |
| Washington | Yes | CN & MN | 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; leave day reimbursement factored into per diem through adjustments | ||
| West Virginia | Yes | A, B & C | 12 hosp leave days/year, 6 therapeutic leave days/year | Yes | Prospective cost related and acuity adjusted per diem with limits based on operating costs plus capital, payment for leave days dependent on level of occupancy | |
| Wisconsin | Yes | CN & MN | 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 for leave days | Specialized med equipment and for care of ventilator dependent persons | Prospective per diem based on cost compared to a target adjusted for casemix, leave days paid at 25% of facility's casemix adjusted rate | |
| Wyoming | Yes | CN | 14 leave days of any type/year | Admission of a child under 21 | Prospective per diem based on cost with efficiency incentives, higher rates for heavy care residents, full per diem paid for leave days if facility has at least 90% occupancy |
2010
| Location | Benefit Covered | Coverage Code | Copayment Required? | Limit on services days | Prior Approval Required | Reimbursement Methodology |
|---|---|---|---|---|---|---|
| United States | Yes - 54 No - 2 | Yes - 0 No - 54 | ||||
| Alabama | Yes | CN | 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 | ||
| Alaska | Yes | CN | Hosp leave days not covered, unlimited therapeutic leave days/year up to 5 days consecutively | Initially to determine LOC, initially and periodically for LOS | Prospective per diem based on cost | |
| American Samoa | No | |||||
| Arizona | Yes | CN & MN | Acute Care program members limited to 90 days for convalescence/year, ALTCS members have no LOS limit but are limited to 12 hosp leave days/year and 9 therapeutic leave days/year | Admission | Prospective per diem based on resident class/acuity, negotiated rates for heavy care residents and certain facilities | |
| Arkansas | Yes | CN | 5 hosp leave days/hospitalization, facility must have 85% occupancy rate to be paid, unlimited therapeutic leave days up to 14 days consecutively; home-style facility regulations incorporated into policy | Prospective cost based per diem | ||
| California | Yes | CN & MN | 30 days for mentally disabled persons or persons in mental health therapeutic programs, 73 days for developmentally disabled, 7 hosp leave days/hospitalization, 18 therapeutic leave days/year | Specialized rehab services, higher payment for complex cases, e.g., ventilator dependent | Standard per diem by facility size, location and level of care; state may negotiate all-inclusive rates with certain facilities | |
| Colorado | Yes | CN | Hosp leave days not covered, 42 therapeutic leave days/year | Prospective per diem based on cost, acuity adjusted, with limits | ||
| Connecticut | Yes | CN & MN | 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 | ||
| Delaware | Yes | CN | 7 hosp leave days/month, 18 therapeutic leave days/year | Prospective per diem based on cost and acuity, up to Medicare limits | ||
| District of Columbia | Yes | CN & MN | 18 days hosp or therapeutic leave/year | Prospective per diem based on cost, with efficiency incentives, up to Medicare limits | ||
| Florida | Yes | CN | 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 | ||
| Georgia | Yes | CN | Limited to facilities dually certified for Medicare, 7 hosp leave days/hospitalization, 8 therapeutic leave days/year | For LOC determination upon admission | Prospective cost based per diem with limits, leave days paid 75% of per diem | |
| Guam | Yes | CN | 180 days/year | Negotiated rate/service | ||
| Hawaii | Yes | CN & MN | Prospective cost based per diem | |||
| Idaho | Yes | CN | 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 | Admission | Prospective per diem with limits, leave days paid at 75% of allowable costs | |
| Illinois | Yes | CN & MN | 10 hosp leave days/month and 10 therapeutic leave days/month (7 consecutive), facility must have minimum 93% occupancy rate and 90% Medicaid-eligible occupancy to be paid | Yes | 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; facilities paid special rates for serving ventilator-dependent residents | |
| Indiana | Yes | CN | 15 consecutive hosp leave days/hosp, 30 therapeutic leave days/year | For LOC determination upon admission, therapies, specified prescription drugs | Prospective per diem based on cost, leave days paid at 50% of facility's rate if 90% occupancy requirement met | |
| Iowa | Yes | CN | Prospective per diem based on resident acuity | |||
| Kansas | Yes | CN & MN | 10 hosp leave days/acute care hospitalization, 18 hosp leave days/psychiatric hospitalization | Admission of a child under age 16 | Prospective per diem based on cost, leave days paid at 67% of facility's rate | |
| Kentucky | Yes | C - See state-specific FN | Benefit limited to short-term acute conditions, 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 | ||
| Louisiana | Yes | CN & MN | 7 hosp leave days/hospitalization, 15 therapeutic leave days/year | For LOC determination upon admission | Private facilities paid prospective acuity adjusted per diem, cost based per diem up to Medicare limits for public facilities, leave days paid percentage of per diem dependent upon occupancy rate | |
| Maine | Yes | CN & MN | 10 hosp leave days/year, 36 therapeutic leave days/year | Prospective per diem based on cost, up to Medicare limits | ||
| Maryland | Yes | CN & MN | 15 hosp leave days/hospitalization, 18 therapeutic leave days/year | Cost based reimbursement | ||
| Massachusetts | Yes | CN & MN | 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 | ||
| Michigan | Yes | CN & MN | 10 hosp leave days/hosp, 18 therapeutic leave days/year | Therapies and customized med equipment | Prospective per diem based on cost with limits | |
| Minnesota | Yes | A - See state-specific FN | 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 | ||
| Mississippi | Yes | CN | 30 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 | ||
| Missouri | Yes | CN | 3 hospital leave days/hospitalization if specified criteria met, 12 therapeutic leave days/6 months | Prospective per diem based on cost | ||
| Montana | Yes | A & B - See state-specific FN | Hosp leave days covered if facility is full with a waiting list and resident expected to return, 24 therapeutic leave days/year | Therapeutic leave exceeding 3 days | Prospective per diem using statewide price limits, acuity adjusted | |
| Nebraska | Yes | CN & MN | 15 hosp leave days/hospitalization, 18 therapeutic leave days/year | Admission of beneficiaries over age 64 | Prospective cost based per diem adjusted for acuity, with limits | |
| Nevada | Yes | CN | 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 | ||
| New Hampshire | Yes | CN & MN | Hosp leave days not covered, therapeutic leave limited to 30 days/year if established criteria met | Prospective per diem based on cost, acuity adjusted | ||
| New Jersey | Yes | CN | 10 hosp leave days/hospitalization, 24 therapeutic leave days/year | Prospective per diem based on cost with incentives for high occupancy | ||
| New Mexico | Yes | CN | 6 leave days/year of any type with additional 6 days allowed if approved; A - benefit limited to post-acute treatment for rehab | Admission | Prospective per diem based on cost, with limits, leave days paid at 50% of per diem rate | |
| New York | Yes | CN & MN | 15 hosp leave days/hosp; 18 therapeutic leave days/year; facility must have 95% or higher occupancy rate to be paid | Prospective per diem based on cost using peer groups and acuity adjusted | ||
| North Carolina | Yes | CN & MN | Hosp leave days not covered, 15 consecutive therapeutic leave days up to 60 days/year | Admission review required to assure appropriate level of care | Prospective per diem based on cost, with limits; quarterly adjustment based on facility casemix index | |
| North Dakota | Yes | CN & MN | 15 hosp leave days/hospitalization, 24 therapeutic leave days/year | Prospective per diem based on cost, acuity adjusted, with limits | ||
| Northern Mariana Islands | Yes | CN & MN - See territory-specific FN | Post hospital extended care only | |||
| Ohio | Yes | CN | 30 hosp or therapeutic leave days/year, leave days not covered for residents receiving hospice care | Prospective per diem with limits and acuity adjustment, leave days paid one-half of per diem rate | ||
| Oklahoma | Yes | CN | 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 | ||
| Oregon | Yes | A - See state-specific FN | Leave days not covered | Prospective per diem based on cost | ||
| Pennsylvania | Yes | CN & MN | 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 | ||
| Puerto Rico | No - see territory-specific FN | |||||
| Rhode Island | Yes | See state-specific FN | Leave days not covered | Prospective per diem based on cost, acuity adjusted | ||
| South Carolina | Yes | CN | 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 | ||
| South Dakota | Yes | CN | 5 hosp leave days/hospitalization, 15 consecutive therapeutic leave days if in plan of care | For LOC determination upon admission | Prospective per diem based on cost, with limits | |
| Tennessee | Yes | A - See state-specific FN | 10 leave days of any type/year but limited to level 1 facilities | Admission | 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 | |
| Texas | Yes | CN & MN | 3 consecutive therapeutic leave days | Admission | Prospective per diem based on cost and acuity adjusted, higher rates for heavy care residents, hospice room and board paid 95% of per diem rate | |
| Utah | Yes | A - See state-specific FN | 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 | ||
| Vermont | Yes | A & B - See state-specific FN | B - 30 days/stay up to 60 days/year and only covered under PC Plus; A & B - 6 hosp leave days/hospitalization and 24 therapeutic leave days/year | Prospective per diem | ||
| U.S. Virgin Islands | Yes | CN | Cost based per diem, up to Medicare limits | |||
| Virginia | Yes | CN & MN | Hosp leave days not covered, 18 therapeutic leave days/year | Admission | Prospective per diem based on cost and acuity adjusted | |
| Washington | Yes | CN & MN | 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 | ||
| West Virginia | Yes | A, B & C | 12 hosp leave days/year, 6 therapeutic leave days/year | Yes | Prospective cost related and acuity adjusted per diem with limits based on operating costs plus capital | |
| Wisconsin | Yes | CN & MN | 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 for leave days | Specialized med equipment and for care of ventilator dependent persons | Prospective per diem based on cost compared to a target adjusted for casemix, leave days paid at 25% of facility's casemix adjusted rate | |
| Wyoming | Yes | CN | Admission of a child under 21 | Prospective per diem based on cost with efficiency incentives, higher rates for heavy care residents |
2008
| Location | Benefit Covered | Coverage Code | Copayment Required? | Limit on services days | Prior Approval Required | Reimbursement Methodology |
|---|---|---|---|---|---|---|
| United States | Yes - 55 No - 1 | Yes - 0 No - 55 | ||||
| Alabama | Yes | CN | 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 | ||
| Alaska | Yes | CN | Hosp leave days not covered, unlimited therapeutic leave days/year up to 5 days consecutively | Initially to determine LOC, initially and periodically for LOS | Prospective per diem based on cost | |
| American Samoa | Yes | See territory-specific FN | Post hospital extended care only | |||
| Arizona | Yes | CN & MN | 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 | Admission | Prospective per diem based on resident class/acuity, negotiated rates for heavy care residents and certain facilities | |
| Arkansas | Yes | CN | 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 | ||
| California | Yes | CN & MN | 30 treatment absences in 120 days for rehab therapy, 7 hosp leave days/hospitalization, 18 therapeutic leave days/year | Specialized rehab services, higher payment for complex cases, e.g., ventilator dependent | Standard per diem by facility size, location and level of care; state may negotiate all-inclusive rates with certain facilities | |
| Colorado | Yes | CN | Hosp leave days not covered, 42 therapeutic leave days/year | Prospective per diem based on cost, acuity adjusted, with limits | ||
| Connecticut | Yes | CN & MN | 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 | ||
| Delaware | Yes | CN | 7 hosp leave days/month, 18 therapeutic leave days/year | Prospective per diem based on cost and acuity, up to Medicare limits | ||
| District of Columbia | Yes | CN & MN | 18 days hosp or therapeutic leave/year | Prospective per diem based on cost, with efficiency incentives, up to Medicare limits | ||
| Florida | Yes | CN | 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 | ||
| Georgia | Yes | CN | Limited to facilities dually certified for Medicare, 7 hosp leave days/hospitalization, 8 therapeutic leave days/year | For LOC determination upon admission | Prospective cost based per diem with limits, leave days paid 75% of per diem | |
| Guam | Yes | CN | 180 days/year | Negotiated rate/service | ||
| Hawaii | Yes | CN & MN | 12 hosp or therapeutic leave days/year, up to 3 consecutive days | Prospective cost based per diem | ||
| Idaho | Yes | CN | 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 | Admission | Prospective per diem with limits, leave days paid at 75% of allowable costs | |
| Illinois | Yes | CN & MN | 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 | ||
| Indiana | Yes | CN | 15 consecutive hosp leave days/hosp, 30 therapeutic leave days/year | For LOC determination upon admission, therapies, specified prescription drugs | Prospective per diem based on cost, leave days paid at 50% of facility's rate if 90% occupancy requirement met | |
| Iowa | Yes | CN | 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 | ||
| Kansas | Yes | CN & MN | 10 hosp leave days/acute care hospitalization, 18 hosp leave days/psychiatric hospitalization | Admission of a child under age 16 | Prospective per diem based on cost, leave days paid at 67% of facility's rate | |
| Kentucky | Yes | C - See state-specific FN | 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 | ||
| Louisiana | Yes | CN & MN | 7 hosp leave days/hospitalization, 15 therapeutic leave days/year | For LOC determination upon admission | Private facilities paid prospective acuity adjusted per diem, cost based per diem up to Medicare limits for public facilities | |
| Maine | Yes | CN & MN | 10 hosp leave days/year, 36 therapeutic leave days/year | Prospective per diem based on cost, up to Medicare limits | ||
| Maryland | Yes | CN & MN | 15 hosp leave days/hospitalization, 18 therapeutic leave days/year | Cost based reimbursement | ||
| Massachusetts | Yes | CN & MN | 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 | ||
| Michigan | Yes | CN & MN | 10 hosp leave days/hosp, 18 therapeutic leave days/year | Therapies and customized med equipment | Prospective per diem based on cost with limits, reduced per diem paid for hospital leave days and only if 98% occupancy requirement met | |
| Minnesota | Yes | A - See state-specific FN | 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 | ||
| Mississippi | Yes | CN | 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 | ||
| Missouri | Yes | CN | 12 therapeutic leave days/6 months | Prospective per diem based on cost | ||
| Montana | Yes | A & B - See state-specific FN | Hosp leave days not covered, 24 therapeutic leave days/year | Therapeutic leave exceeding 3 days | Prospective per diem using statewide price limits, acuity adjusted | |
| Nebraska | Yes | CN & MN | 15 hosp leave days/hospitalization, 18 therapeutic leave days/year | Admission of beneficiaries over age 64 | Prospective cost based per diem, with limits | |
| Nevada | Yes | CN | 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 | ||
| New Hampshire | Yes | CN & MN | 30 reserve bed days/year if established criteria met | Prospective per diem based on cost, acuity adjusted | ||
| New Jersey | Yes | CN | 10 hosp leave days/hospitalization, 24 therapeutic leave days/year | Prospective per diem based on cost with incentives for high occupancy, hosp leave days paid at 50% of per diem rate | ||
| New Mexico | Yes | CN | 6 leave days/year of any type with additional 6 days allowed if approved | Admission | Prospective per diem based on cost, with limits, leave days paid at 50% of per diem rate | |
| New York | Yes | CN & MN | Prospective per diem based on cost using peer groups and acuity adjusted | |||
| North Carolina | Yes | CN & MN | Hosp leave days not covered, 15 consecutive therapeutic leave days up to 60 days/year | Admission | Prospective per diem based on cost, with limits | |
| North Dakota | Yes | CN & MN | 15 hosp leave days/hospitalization, 24 therapeutic leave days/year | Prospective per diem based on cost, acuity adjusted, with limits | ||
| Northern Mariana Islands | Yes | CN & MN - See territory-specific FN | Post hospital extended care only | |||
| Ohio | Yes | CN | 30 hosp or therapeutic leave days/year | Prospective per diem with limits and acuity adjustment, leave days paid one-half of per diem rate | ||
| Oklahoma | Yes | CN | 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 | ||
| Oregon | Yes | A - See state-specific FN | Leave days not covered | Prospective per diem based on cost | ||
| Pennsylvania | Yes | CN & MN | 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 | ||
| Puerto Rico | No - see territory-specific FN | |||||
| Rhode Island | Yes | CN & MN - see state-specific FN | Leave days not covered | Prospective per diem based on cost, with efficiency incentives and occupancy adjustments | ||
| South Carolina | Yes | CN | 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 | ||
| South Dakota | Yes | CN | 5 hosp leave days/hospitalization, 15 consecutive therapeutic leave days if in plan of care | For LOC determination upon admission | Prospective per diem based on cost, with limits | |
| Tennessee | Yes | A - See state-specific FN | 10 leave days of any type/year but limited to level 1 facilities | Admission | 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 | |
| Texas | Yes | CN & MN | 3 consecutive therapeutic leave days | Admission | Prospective per diem based on cost and acuity adjusted, higher rates for heavy care residents | |
| Utah | Yes | A - See state-specific FN | 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 | ||
| Vermont | Yes | A & B - See state-specific FN | 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 | ||
| U.S. Virgin Islands | Yes | CN | Cost based per diem, up to Medicare limits | |||
| Virginia | Yes | CN & MN | 18 therapeutic leave days/year | Admission | Prospective per diem based on cost and acuity adjusted | |
| Washington | Yes | CN & MN | 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 | ||
| West Virginia | Yes | A, B & C | 12 hosp leave days/year, 6 therapeutic leave days/year | Yes | Prospective cost related and acuity adjusted per diem with limits based on operating costs plus capital | |
| Wisconsin | Yes | CN & MN | 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 | Specialized med equipment and for care of ventilator dependent persons | Prospective per diem based on cost compared to a target adjusted for casemix, leave days paid at 25% of facility's casemix adjusted rate | |
| Wyoming | Yes | CN | 14 leave days of any type/year | Admission of a child under 21 | Prospective per diem based on cost with efficiency incentives, higher rates for heavy care residents |
2006
| Location | Benefit Covered | Coverage Code | Copayment Required? | Limit on services days | Prior Approval Required | Reimbursement Methodology |
|---|---|---|---|---|---|---|
| United States | Yes - 55 No - 1 | Yes - 0 No - 55 | ||||
| Alabama | Yes | CN | 4 hosp leave days/hospitalization, 3 therapeutic leave days/absence up to 2 absences/quarter or 6/year | Prospective per diem based on cost and facility class | ||
| Alaska | Yes | CN | Hosp leave days not covered, unlimited therapeutic leave days/year up to 5 days consecutively | Initially to determine LOC, initially and periodically for LOS | Prospective per diem based on cost | |
| American Samoa | Yes | See territory-specific FN | Post hospital extended care only | |||
| Arizona | Yes | CN & MN | 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 | Admission | Prospective per diem based on resident class/acuity, negotiated rates for heavy care residents and certain facilities | |
| Arkansas | Yes | CN | 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 | ||
| California | Yes | CN & MN | 30 treatment absences in 120 days for rehab therapy, 7 hosp leave days/hospitalization, 18 therapeutic leave days/year | Specialized rehab services, higher payment for complex cases, e.g., ventilator dependent | Standard per diem by facility size, location and level of care; state may negotiate all-inclusive rates with certain facilities | |
| Colorado | Yes | CN | Hosp leave days not covered, 42 therapeutic leave days/year | Prospective per diem based on cost, acuity adjusted, with limits | ||
| Connecticut | Yes | CN & MN | 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 | ||
| Delaware | Yes | CN | 7 hosp leave days/month, 18 therapeutic leave days/year | Prospective per diem based on cost and acuity, up to Medicare limits | ||
| District of Columbia | Yes | CN & MN | 18 days hosp or therapeutic leave/year | Prospective per diem based on cost, with efficiency incentives, up to Medicare limits | ||
| Florida | Yes | CN | 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 | ||
| Georgia | Yes | CN | Limited to facilities dually certified for Medicare, 7 hosp leave days/hospitalization, 8 therapeutic leave days/year | For LOC determination upon admission | Prospective cost based per diem with limits, leave days paid 75% of per diem | |
| Guam | Yes | CN | 180 days/year | Negotiated rate/service | ||
| Hawaii | Yes | CN & MN | 12 hosp or therapeutic leave days/year, up to 3 consecutive days | Prospective per diem based on cost, up to Medicare limits | ||
| Idaho | Yes | CN | Services limited to Enhanced Plan, hosp leave days not covered, 3 therapeutic leave days per home visit covered up to 15 days/year - See state-specific FN | Admission | Prospective per diem based on resident class/acuity, leave days paid at 75% of allowable costs and facility must have fewer than 5 or 5% of its licensed beds vacant to be paid | |
| Illinois | Yes | CN & MN | 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 | ||
| Indiana | Yes | CN | 15 hosp leave days/hosp, 30 therapeutic leave days/year | For LOC determination upon admission, therapies, specified prescription drugs | Prospective per diem based on cost, leave days paid at 50% of facility's rate if 90% occupancy requirement met | |
| Iowa | Yes | CN | 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 | ||
| Kansas | Yes | CN & MN | 10 hosp leave days/month in general hospital and 21 days in psych hospital, 12 therapeutic leave days/year | Admission of a child under age 16 | Prospective per diem based on cost, leave days paid at 67% of facility's rate | |
| Kentucky | Yes | C - See state-specific FN | 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 | ||
| Louisiana | Yes | CN & MN | 7 hosp leave days/hospitalization, 15 therapeutic leave days/year | For LOC determination upon admission | Private facilities paid prospective acuity adjusted per diem, cost based per diem up to Medicare limits for public facilities | |
| Maine | Yes | CN & MN | 10 hosp leave days/year, 36 therapeutic leave days/year | Prospective per diem based on cost, up to Medicare limits | ||
| Maryland | Yes | CN & MN | 15 hosp leave days/hospitalization, 18 therapeutic leave days/year | Cost based reimbursement | ||
| Massachusetts | Yes | CN & MN | 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 | ||
| Michigan | Yes | CN & MN | 10 hosp leave days/hosp, 18 therapeutic leave days/year | Therapies and customized med equipment | Prospective per diem based on cost with limits, reduced per diem paid for hospital leave days and only if 98% occupancy requirement met | |
| Minnesota | Yes | A - See state-specific FN | 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 | ||
| Mississippi | Yes | CN | 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 | ||
| Missouri | Yes | CN | 12 therapeutic leave days/6 months | Prospective per diem based on cost | ||
| Montana | Yes | A & B - See state-specific FN | Hosp leave days covered if facility is full with waiting list, 72 hour maximum therapeutic leave up to 24 days/year | Prospective per diem using statewide price limits, acuity adjusted | ||
| Nebraska | Yes | CN & MN | 15 hosp leave days/hospitalization, 18 therapeutic leave days/year | Admission of beneficiaries over age 64 | Prospective cost based per diem, with limits | |
| Nevada | Yes | CN | 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 | ||
| New Hampshire | Yes | CN & MN | 10 therapeutic leave days/year | Prospective per diem based on cost, acuity adjusted | ||
| New Jersey | Yes | CN | 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 | ||
| New Mexico | Yes | CN | 6 leave days/year of any type with additional 6 days allowed if approved | Admission | Prospective per diem based on cost, with limits, leave days paid at 50% of per diem rate | |
| New York | Yes | CN & MN | Prospective per diem based on cost using peer groups and acuity adjusted | |||
| North Carolina | Yes | CN & MN | Hosp leave days not covered, 15 consecutive therapeutic leave days up to 60 days/year | Admission | Prospective per diem based on cost, with limits | |
| North Dakota | Yes | CN & MN | 15 hosp leave days/hospitalization, 24 therapeutic leave days/year | Prospective per diem based on cost, acuity adjusted, with limits | ||
| Northern Mariana Islands | Yes | CN & MN - See territory-specific FN | Post hospital extended care only | |||
| Ohio | Yes | CN | 30 hosp or therapeutic leave days/year | Prospective cost based per diem with limits, leave days paid one-half of per diem rate | ||
| Oklahoma | Yes | CN | 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 | ||
| Oregon | Yes | A - See state-specific FN | Leave days not covered | Prospective per diem based on cost | ||
| Pennsylvania | Yes | CN & MN | 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 | ||
| Puerto Rico | No - see territory-specific FN | |||||
| Rhode Island | Yes | CN & MN - see state-specific FN | Leave days not covered | Prospective per diem based on cost, with efficiency incentives and occupancy adjustments | ||
| South Carolina | Yes | CN | 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 | ||
| South Dakota | Yes | CN | 5 hosp leave days/hospitalization, 15 consecutive therapeutic leave days if in plan of care | For LOC determination upon admission | Prospective per diem based on cost, with limits | |
| Tennessee | Yes | A - See state-specific FN | 10 leave days of any type/year but limited to level 1 facilities | Admission | 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 | |
| Texas | Yes | CN & MN | 3 consecutive therapeutic leave days | Admission | Prospective per diem based on cost and acuity adjusted, higher rates for heavy care residents | |
| Utah | Yes | A - See state-specific FN | 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 | ||
| Vermont | Yes | A & B - See state-specific FN | 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 based on cost and assuming 90% occupancy except for new or very small facilities, leave day payment contingent upon facility occupancy rate | ||
| U.S. Virgin Islands | Yes | CN | Cost based per diem, up to Medicare limits | |||
| Virginia | Yes | CN & MN | Hosp leave days not covered, 7 consecutive therapeutic leave days up to 18 days/year | Admission | Prospective per diem based on cost and acuity adjusted | |
| Washington | Yes | CN & MN | 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 | ||
| West Virginia | Yes | CN & MN | 12 hosp leave days/year, 6 therapeutic leave days/year | Prospective cost related and acuity adjusted per diem with limits based on operating costs plus capital | ||
| Wisconsin | Yes | CN & MN | 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 | Specialized med equipment | Prospective per diem based on cost using peer groups with some settlement | |
| Wyoming | Yes | CN | 14 leave days of any type/year | Admission of a child under 21 | Prospective per diem based on cost with efficiency incentives, higher rates for heavy care residents |
2004
| Location | Benefit Covered | Coverage Code | Copayment Required? | Limit on services days | Prior Approval Required | Reimbursement Methodology |
|---|---|---|---|---|---|---|
| United States | Yes - 55 No - 1 | Yes - 0 No - 55 | ||||
| Alabama | Yes | CN | 4 hosp leave days/hospitalization, 3 therapeutic leave days/absence up to 2 absences/quarter or 6/year | Prospective per diem based on cost and facility class | ||
| Alaska | Yes | CN | Hosp leave days not covered, unlimited therapeutic leave days/year up to 5 days consecutively | Initially to determine LOC, initially and periodically for LOS | Prospective per diem based on cost | |
| American Samoa | Yes | See territory-specific FN | Post hospital extended care only | |||
| Arizona | Yes | CN & MN | Acute Care program members limited to 90 days for convalescence/year - see state-specific FN, 12 hosp leave days/year, 9 therapeutic leave days/year | Admission | Prospective per diem based on resident class/acuity, negotiated rates for heavy care residents and certain facilities | |
| Arkansas | Yes | CN | 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 | ||
| California | Yes | CN & MN | 30 treatment absences in 120 days for rehab therapy, 7 hosp leave days/hospitalization, 18 therapeutic leave days/year | Specialized rehab services, higher payment for complex cases, e.g., ventilator dependent | Standard per diem by facility size, location and level of care; state may negotiate all-inclusive rates with certain facilities | |
| Colorado | Yes | CN | Hosp leave days not covered, 42 therapeutic leave days/year | Prospective per diem based on cost, acuity adjusted, with limits | ||
| Connecticut | Yes | CN & MN | 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 | ||
| Delaware | Yes | CN | 7 hosp leave days/month, 18 therapeutic leave days/year | Prospective per diem based on cost, up to Medicare limits | ||
| District of Columbia | Yes | CN & MN | 18 days hosp or therapeutic leave/year | Prospective per diem based on cost, with efficiency incentives, up to Medicare limits | ||
| Florida | Yes | CN | 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 | ||
| Georgia | Yes | CN | 7 hosp leave days/hospitalization, 8 therapeutic leave days/year | Prospective per diem based on cost, with limits; leave days paid 75% of per diem | ||
| Guam | Yes | CN | 180 days/year | Negotiated rate/service | ||
| Hawaii | Yes | CN & MN | 12 hosp or therapeutic leave days/year, up to 3 consecutive days | Prospective per diem based on cost, up to Medicare limits | ||
| Idaho | Yes | CN | 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 | Admission | Prospective per diem based on resident class/acuity, leave days paid at 75% of allowable costs | |
| Illinois | Yes | CN & MN | 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 | ||
| Indiana | Yes | CN | 15 hosp leave days/hosp, 30 therapeutic leave days/year | For LOC determination upon admission, therapies, specified prescription drugs | Prospective per diem based on cost, leave days paid at 50% of facility's rate if 90% occupancy requirement met | |
| Iowa | Yes | CN | 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 | ||
| Kansas | Yes | CN & MN | 10 hosp leave days/month in general hospital and 21 days in psych hospital, 12 therapeutic leave days/year | Admission of a child under age 16 | Prospective per diem based on cost, leave days paid at 67% of facility's rate | |
| Kentucky | Yes | CN | 14 hosp leave days/hospitalization up to 45 days/year, 15 therapeutic leave days/year | Prospective per diem by resident class/acuity, cost based payment for ancillary services | ||
| Louisiana | Yes | CN & MN | 7 hosp leave days/hospitalization, 15 therapeutic leave days/year | For LOC determination upon admission | Private facilities paid prospective acuity adjusted per diem, cost based per diem up to Medicare limits for public facilities | |
| Maine | Yes | CN & MN | 10 hosp leave days/year, 36 therapeutic leave days/year | Prospective per diem based on cost, up to Medicare limits | ||
| Maryland | Yes | CN & MN | 15 hosp leave days/hospitalization, 18 therapeutic leave days/year | Cost based reimbursement | ||
| Massachusetts | Yes | CN & MN | 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 | ||
| Michigan | Yes | CN & MN | 10 hosp leave days/hosp, 18 therapeutic leave days/year | Therapies and customized med equipment | Prospective per diem based on cost with limits, reduced per diem paid for hospital leave days | |
| Minnesota | Yes | A - See state-specific FN | 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 adjusted, leave days paid at 60% of facility's rate | ||
| Mississippi | Yes | CN | 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 | ||
| Missouri | Yes | CN | 3 hosp leave days/hospitalization, 12 therapeutic leave days/6 months | Prospective per diem based on cost | ||
| Montana | Yes | A & B - See state-specific FN | Hosp leave days covered if facility is full with waiting list, 72 hour maximum therapeutic leave up to 24 days/year | Prospective per diem using statewide price limits, acuity adjusted | ||
| Nebraska | Yes | CN & MN | 15 hosp leave days/hospitalization, 18 therapeutic leave days/year | Admission of beneficiaries over age 64 | Prospective cost based per diem, with limits | |
| Nevada | Yes | CN | 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 | ||
| New Hampshire | Yes | CN & MN | 10 therapeutic leave days/year | Prospective per diem based on cost, acuity adjusted | ||
| New Jersey | Yes | CN | 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 90% of per diem rate | ||
| New Mexico | Yes | CN | 6 leave days/year of any type with additional 6 days allowed if approved | Admission | Prospective per diem based on cost, with limits, payment for leave days at 50% of per diem rate | |
| New York | Yes | CN & MN | Prospective per diem based on cost using peer groups and acuity adjusted | |||
| North Carolina | Yes | CN & MN | Hosp leave days not covered, 15 consecutive therapeutic leave days up to 60 days/year | Admission | Prospective per diem based on cost, with limits | |
| North Dakota | Yes | CN & MN | 15 hosp leave days/hospitalization, 24 therapeutic leave days/year | Prospective per diem based on cost, acuity adjusted, with limits | ||
| Northern Mariana Islands | Yes | CN & MN - See territory-specific FN | Post hospital extended care only | |||
| Ohio | Yes | CN | 30 hosp or therapeutic leave days/year | Prospective cost based per diem with limits, leave days paid one-half of per diem rate | ||
| Oklahoma | Yes | CN | 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 | ||
| Oregon | Yes | A - See state-specific FN | Leave days not covered | Prospective per diem based on cost | ||
| Pennsylvania | Yes | CN & MN | 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 | ||
| Puerto Rico | No - see territory-specific FN | |||||
| Rhode Island | Yes | CN & MN - see state-specific FN | Leave days not covered | Prospective per diem based on cost, with efficiency incentives and occupancy adjustments | ||
| South Carolina | Yes | CN | 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 | ||
| South Dakota | Yes | CN | 5 hosp leave days/hospitalization, 15 consecutive therapeutic leave days if in plan of care | For LOC determination upon admission | Prospective per diem based on cost, with limits | |
| Tennessee | Yes | A - See state-specific FN | Admission | 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 | ||
| Texas | Yes | CN & MN | 3 consecutive therapeutic leave days | Admission | Prospective per diem based on cost and acuity adjusted, higher rates for heavy care residents | |
| Utah | Yes | A - See state-specific FN | 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 | ||
| Vermont | Yes | A & B - See state-specific FN | 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 based on cost and assuming 90% occupancy except for new or very small facilities, leave day payment contingent upon facility occupancy rate | ||
| U.S. Virgin Islands | Yes | CN | Cost based per diem, up to Medicare limits | |||
| Virginia | Yes | CN & MN | Hosp leave days not covered, 7 consecutive therapeutic leave days up to 18 days/year | Prospective per diem based on cost and acuity adjusted | ||
| Washington | Yes | CN & MN | 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 | ||
| West Virginia | Yes | CN & MN | 12 hosp leave days/year, 6 therapeutic leave days/year | Prospective cost related and acuity adjusted per diem with limits based on operating costs plus capital | ||
| Wisconsin | Yes | CN & MN | 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 | Specialized med equipment | Prospective per diem based on cost using peer groups with some settlement | |
| Wyoming | Yes | CN | 14 leave days of any type/year | Admission of a child under 21 | Prospective per diem based on cost with efficiency incentives, higher rates for heavy care residents |
2003
| Location | Benefit Covered | Coverage Code | Copayment Required? | Limit on services days | Prior Approval Required | Reimbursement Methodology |
|---|---|---|---|---|---|---|
| United States | Yes - 55 No - 1 | Yes - 0 No - 55 | ||||
| Alabama | Yes | CN | 4 hosp leave days/hospitalization, 3 therapeutic leave days/absence up to 2 absences/quarter or 6/year | Prospective per diem based on cost and facility class | ||
| Alaska | Yes | CN | Hosp leave days not covered, unlimited therapeutic leave days/year up to 5 days consecutively | Admission | Prospective per diem based on cost | |
| American Samoa | Yes | See territory-specific FN | Post hospital extended care only | |||
| Arizona | Yes | CN & MN | Acute Care program members limited to 90 days for convalescence/year - see state-specific FN, 12 hosp leave days/year, 9 therapeutic leave days/year | Admission | Prospective per diem based on resident class/acuity, negotiated rates for heavy care residents and certain facilities | |
| Arkansas | Yes | CN | 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 | ||
| California | Yes | CN & MN | 30 treatment absences in 120 days for rehab therapy, 7 hosp leave days/hospitalization, 18 therapeutic leave days/year | Specialized rehab services, higher payment for complex cases, e.g., ventilator dependent | Standard per diem by facility size, location and level of care; state may negotiate all-inclusive rates with certain facilities | |
| Colorado | Yes | CN | Hosp leave days not covered, 42 therapeutic leave days/year | Prospective per diem based on cost, with limits | ||
| Connecticut | Yes | CN & MN | 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 | ||
| Delaware | Yes | CN | 14 hosp leave days/hospitalization, 18 therapeutic leave days/year | Prospective per diem based on cost, up to Medicare limits | ||
| District of Columbia | Yes | CN & MN | 18 days hosp or therapeutic leave/year | Prospective per diem based on cost, with efficiency incentives, up to Medicare limits | ||
| Florida | Yes | CN | 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 80% occupancy rate in prior quarter | ||
| Georgia | Yes | CN & MN | 7 hosp leave days/hospitalization, 8 therapeutic leave days/year | Prospective per diem based on cost, with limits | ||
| Guam | Yes | CN | 180 days/year | Negotiated rate/service | ||
| Hawaii | Yes | CN & MN | 12 hosp or therapeutic leave days/year, up to 3 consecutive days | Prospective per diem based on cost, up to Medicare limits | ||
| Idaho | Yes | CN | 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 | Admission | Prospective per diem based on resident class/acuity, leave days paid at 75% of allowable costs | |
| Illinois | Yes | CN & MN | 10 hosp leave days/hospitalization, 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 | ||
| Indiana | Yes | CN | 15 hosp leave days/hosp, 18 therapeutic leave days/year | For LOC determination upon admission, therapies, specified prescription drugs | Prospective per diem based on cost, leave days paid at 50% of facility's rate if 90% occupancy requirement met | |
| Iowa | Yes | CN | 10 hosp leave days/hospitalization, 18 therapeutic leave days/year | Prospective per diem based on resident acuity, leave days paid at 75% of facility's rate | ||
| Kansas | Yes | CN & MN | 10 hosp leave days/month in general hospital and 21 days in psych hospital, 12 therapeutic leave days/year | Admission of a child under age 16 | Prospective per diem based on cost, leave days paid at 67% of facility's rate | |
| Kentucky | Yes | CN & MN | 14 hosp leave days/hospitalization up to 45 days/year, 15 therapeutic leave days/year | Prospective per diem by resident class/acuity, cost based payment for ancillary services | ||
| Louisiana | Yes | CN & MN | 7 hosp leave days/hospitalization, 15 therapeutic leave days/year | For LOC determination upon admission | Private facilities paid prospective acuity adjusted per diem, cost based per diem up to Medicare limits for public facilities | |
| Maine | Yes | CN & MN | 10 hosp leave days/year, 36 therapeutic leave days/year | Prospective per diem based on cost, up to Medicare limits | ||
| Maryland | Yes | CN & MN | 15 hosp leave days/hospitalization, 18 therapeutic leave days/year | Cost based reimbursement | ||
| Massachusetts | Yes | CN & MN | 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 | ||
| Michigan | Yes | CN & MN | 10 hosp leave days/hosp, 18 therapeutic leave days/year | Therapies and customized med equipment | Prospective per diem based on cost with limits, reduced per diem paid for hospital leave days | |
| Minnesota | Yes | A - See state-specific FN | 18 hosp leave days/year, 36 therapeutic leave days/year | Prospective per diem with annual legislated rate adjustment, acuity adjusted, leave days paid at 79% of facility's rate | ||
| Mississippi | Yes | CN | 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 | ||
| Missouri | Yes | CN | 3 hosp leave days/hospitalization, 12 therapeutic leave days/6 months | Prospective per diem based on cost | ||
| Montana | Yes | CN & MN | Hosp leave days covered if facility is full with waiting list, 72 hour maximum therapeutic leave up to 24 days/year | Cost based per diem with efficiency incentives, up to Medicare limits | ||
| Nebraska | Yes | CN & MN | 15 hosp leave days/hospitalization, 18 therapeutic leave days/year | Admission of beneficiaries over age 64 | Prospective cost based per diem, with limits | |
| Nevada | Yes | CN | Hosp leave days not covered, one 72-hour maximum therapeutic leave/month up to 96 hours if weekend included | Prospective price-based per diem | ||
| New Hampshire | Yes | CN & MN | 10 therapeutic leave days/year | Prospective per diem based on cost, acuity adjusted | ||
| New Jersey | Yes | CN | 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 90% of per diem rate | ||
| New Mexico | Yes | CN | 6 leave days/year of any type with additional 6 days allowed if approved | Admission | Prospective per diem based on cost, with limits, leave days paid at 50% of per diem rate | |
| New York | Yes | CN & MN | Prospective per diem based on cost using peer groups and acuity adjusted | |||
| North Carolina | Yes | CN & MN | Hosp leave days not covered, 15 consecutive therapeutic leave days up to 60 days/year | Admission | Prospective per diem based on cost, with limits | |
| North Dakota | Yes | CN & MN | 15 hosp leave days/hospitalization, 24 therapeutic leave days/year | Prospective per diem based on cost, acuity adjusted, with limits | ||
| Northern Mariana Islands | Yes | CN & MN - See territory-specific FN | Post hospital extended care only | |||
| Ohio | Yes | CN | 30 hosp or therapeutic leave days/year | Prospective per diem based on cost using peer groups and limits, acuity adjusted | ||
| Oklahoma | Yes | CN | 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 | ||
| Oregon | Yes | CN & MN | Leave days not covered | Prospective per diem based on cost and assuming 95% occupancy | ||
| Pennsylvania | Yes | CN & MN | 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 | ||
| Puerto Rico | No - see territory-specific FN | |||||
| Rhode Island | Yes | CN & MN - see state-specific FN | Leave days not covered | Prospective per diem based on cost, with efficiency incentives and occupancy adjustments | ||
| South Carolina | Yes | CN | 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 | ||
| South Dakota | Yes | CN | 5 hosp leave days/hospitalization, 15 consecutive therapeutic leave days if in plan of care | For LOC determination upon admission | Prospective per diem based on cost, with limits | |
| Tennessee | Yes | A - See state-specific FN | Admission | 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 | ||
| Texas | Yes | CN & MN | 3 consecutive therapeutic leave days | Admission | Prospective per diem based on cost and acuity adjusted, higher rates for heavy care residents | |
| Utah | Yes | A - See state specific FN | 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 | ||
| Vermont | Yes | A & B - See state-specific FN | 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 based on cost and assuming 90% occupancy except for new or very small facilities, leave day payment contingent upon facility occupancy rate | ||
| U.S. Virgin Islands | Yes | CN | Cost based per diem, up to Medicare limits | |||
| Virginia | Yes | CN & MN | Hosp leave days not covered, 7 consecutive therapeutic leave days up to 18 days/year | Prospective per diem based on cost and acuity adjusted | ||
| Washington | Yes | CN & MN | 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 | ||
| West Virginia | Yes | CN & MN | 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 | ||
| Wisconsin | Yes | CN & MN | 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 | Specialized med equipment | Prospective per diem based on cost using peer groups with some settlement | |
| Wyoming | Yes | CN | 14 leave days of any type/year | Admission of a child under 21 | Prospective per diem based on cost with efficiency incentives, higher rates for heavy care residents |