Nursing Facility Providers: How Do Federal And State Medicaid Work In Long-Term Care?

By Kristen A. Moe, Esq.

Nursing facility providers receiving Medicaid funds for their long-term care residents must comply with state and federal statutes that regulate the services offered to residents who qualify for low-income residential care. The following is a broad overview and a guide to a few of the resources that may help those who are interested in Medicaid and Nursing Home facilities, the recipients of healthcare in those facilities, the regulations that apply, and how it all works.

What is Medicaid and How Does It Work?
Medicaid is the single largest federal health program in the U.S. It offers low-income persons health insurance through partnerships with states that implement their own programs pursuant to federal statutes and state regulation. The federal government matches state Medicaid spending based on a formula specified in the Social Security Act (1). Nevada’s Medicaid program is administered through the Department of Health and Human Services (DHHS).

Who Does Medicaid Cover?
Prior to the enactment of the Patient Protection and Affordable Care Act (PPACA), federal law provided Medicaid funding for specific categories of low-income individuals—children, pregnant women, parents of dependent children, individuals with disabilities, and certain Medicare beneficiaries. The PPACA extended coverage to many non-elderly uninsured people nationwide. The June 2012 Supreme Court decision (2) made Medicaid expansion optional for states, and Nevada elected to join the expansion and maximize federal dollars. Effective January 1, 2014, this decision broadened Medicaid eligibility to nearly all adults under age 65 (3) with income at or below 138% of the Federal Poverty Level. Nursing home Medicaid may have a different income limit than home and community-based Medicaid services, and both of those may differ from the Aged, Blind and Disabled income limits (4).

What Services Do Long-Term Care Nursing Home Facilities Provide?
Nursing Home Care is a mandated Medicaid benefit. Nursing Home Long-Term Care Support facilities provide 24/7 health care and services to persons who, due to medical disorders, injuries, developmental disabilities, and/or related cognitive and behavioral impairments, need medical, nursing, rehabilitative or psychosocial management above the level of room and board. Long- Term Care Supports include services for people who cannot live on their own because they need assistance with certain activities of daily living such as bathing, dressing, eating, toileting.
They also provide skilled nursing care and related services for individuals who require medical or nursing care and/or rehabilitation services.

How Are Nursing Long-Term Facilities Regulated?
Both federal and state law regulate long-term care facilities. Federal sources include 42 U.S.C. §1395i-3 and 42 C.F.R. §483. Additionally, the State Operations Manual (SOM) implements the nursing home survey, certification, and enforcement regulations of 42 C.F.R. §488 (5). In Nevada, the Bureau of Health Care Quality and Compliance (BHCQC) oversees Nursing facilities (6). The website includes contact information, an online Complaint form, and a Complaint Process Fact Sheet including information about the prioritization of complaints, and the overall investigation process.

Disagree with a Provider Action?

CORRECTION:   The process for recipients of long-term skilled nursing facilities who disagree with a provider action has been corrected below.

Any recipient of Medicaid services in a long-term skilled nursing facility (with few exceptions) must be provided by the facility with notice of discharge or transfer at least 30 days before the action and must comply with the requirements of both State and Federal law (7). A recipient (or authorized legal representative) may file a Request for Fair Hearing through Department of Health Care Financing and Policy (DHCFP). Within 10 calendar days of the receipt of the request, the Department will set a Hearing Preparation Meeting (HPM), where every effort is made to resolve the disagreement without the necessity for a Fair Hearing. If the disagreement is not resolved, the Hearing Officer will notify the parties by mail as to the  time, date and place the Fair Hearing has been scheduled. All hearings must be tape-recorded as this is the official record (8).

Post-Hearing and Judicial Review
Hearing Officer decisions may be appealed by any party to the appropriate district court in Nevada within 90 days after the date on which the written notice of the decision is mailed (9).
Any aggrieved party may further appeal an adverse district court decision to an appellate court of competent jurisdiction pursuant to the rules fixed by the Supreme Court pursuant to Section 4 of Article 6 of the Nevada Constitution. The appeal must be taken in the manner provided for civil cases (10).

Article Sources:
(1) Nevada Medicaid Fact Book https://dhcfp.nv.gov/, p. 3.
(2) National Federation of Independent Business v. Sebelius, 567 U.S. 519 (2012).
(3) Medicare is federal health insurance for anyone age 65 and older, and some people under 65 with certain disabilities or conditions. Medicaid is a joint federal and state program that gives health coverage to some people with limited income and resources. https://www.hhs.gov
(4) American Council on Aging, https://www.medicaidplanningassistance.org/medicaid-eligibility-income-chart
(5) https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/som107c07pdf.pdf
(6) Division of Public and Behavioral Health https://dpbh.nv.gov/Reg/HealthFacilities/HealthFacilities_-_Home/
(7) NAC §449.74429; 42 C.F.R. §483.15
(8) Division of Health Care Policy and Finance, Medical Services Manual, Sec. 3104-3105.
(9) N.R.S. 422.2785(2).
(10) N.R.S. 422.279(4).