Nursing Facility Services for Individuals Age 21 and Older

Nursing facility services for individuals age 21 and older is a mandatory Medicaid benefit. Nursing facilities are institutions which primarily provide:

• skilled nursing care and related services for residents who require medical or nursing care;
• rehabilitation services for the rehabilitation of injured, disabled or sick persons; or
• on a regular basis, health-related care and services to individuals who because of their mental or physical condition require care and services, above the level of room and board, which can be made available to them only through institutional facilities.

A nursing facility that participates in Medicaid must provide, or arrange for, the full range of services for residents who need them, from those services above the level of room and board which can be made available only through institutional facilities, up to and including skill nursing care.

Nursing facilities are required to meet a number of requirements relating to provision of services, residents' rights and administration.

In general, to the extent needed to fulfill all plans of care, a nursing facility must provide, or arrange for the provision of:

• nursing and related services and specialized rehabilitative services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident;
• medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident;
• pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals) to meet the needs of each resident;
• dietary services that assure that the meals meet the daily nutritional and special dietary needs of each resident;
• an on-going program, directed by a qualified professional, of activities designed to meet the interests and the physical, mental, and psychosocial well-being of each resident;
• routine dental services (to the extent covered under the State plan) and emergency dental services to meet the needs of each resident; and
• treatment and services required by mentally ill and mentally retarded residents not otherwise provided or arranged for (or required to be provided or arranged for) by the State.

 

Resident’s rights.

Each nursing facility resident has a right to a dignified existence, self-determination and communication with and access to persons and services inside and outside the facility. A facility must protect the rights of each resident. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

• The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his/her rights.
• In the case of a resident who has been adjudged incompetent by a court, the rights of the resident are exercised by a person appointed to act on the person's behalf.
• In the case of a resident who has not been adjudged incompetent by the court, any legal-surrogate designated in accordance with State law may exercise the resident's rights to the extent provided by State law.
• The facility must inform the resident both orally and in writing, in a language that the resident understands, of his/her rights and all rules and regulations concerning resident conduct and responsibilities during his/her stay in the facility. This notice must be made prior to or upon admission and during the person's stay. Receipt of the information must be acknowledged in writing.
• The resident has the right to access all records pertaining to himself or herself, including current clinical records within 24 hours (excluding weekend and holidays). At the cost of the community standard, the individual has a right to a copy of the records or any portion of the records.
• The resident has the right to be fully informed, in language that he/she can understand, of his/her total health status.
• The resident has the right to refuse treatment; to refuse to participate in experimental research; and to formulate an advance directive.
• The facility must inform each Medicaid resident, in writing:

 

The items and services that are included in the facility payment for which the resident may not be charged.

Those other items and services that the facility offers, for which the resident may be charged, and the cost for those services.The resident must be informed when changes are made to the items, services, and costs.

• The facility must furnish a written description of legal rights.
• The facility must inform each resident of the name, specialty, and way of contacting the physician responsible for his/her care.
• The facility must prominently display, in the facility, written information and provide applicants for admission, oral and written information about how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments covered by such benefits.
• A facility must immediately inform the resident; consult with the resident's physician; and, if known, notify the resident's legal representative or an interested family member when there is:
• an accident involving the resident which results in injury and has the potential for requiring physician intervention;
• a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications;
• a need to change treatment significantly; or
• a decision to transfer or discharge the resident from the facility.

The resident has the right to manage his or her financial affairs, and the facility may not require residents to deposit their personal funds with the facility. If a resident does deposit funds with the facility, regulations specify how those moneys will be treated and protected.

Services included in the Medicare and Medicaid payment.

During the course of a covered Medicare or Medicaid stay, facilities may not charge a resident for the following categories of items and services:

• Nursing services.
• Dietary services.
• An activities program.
• Room/bed maintenance services.
• Routine personal hygiene items and services, as required, to meet the needs of residents, including, but not limited to: hair hygiene supplies, comb., brush, bath soap, disinfecting soaps or specialized cleansing agents, when indicated to treat special skin problems or to fight infection, razor, shaving cream, toothbrush, toothpaste, denture adhesive, denture cleaner, dental floss, moisturizing lotion, tissues, cotton balls, cotton swabs, deodorant, incontinence care and supplies, sanitary napkins, and related supplies, towels, washcloths, hospital gowns, over the counter drugs, hair and nail hygiene services, bathing, and basic personal laundry.
• Medically-related social services.
• Items and services that may be charged to residents' funds.

General categories and examples of items and services that the facility may charge to residents' funds if they are requested by a resident, if the facility informs the resident that there will be a charge and if payment is not made by Medicaid or Medicare:

• Telephone
• Television/radio for personal use.
• Personal comfort items, including smoking materials, notions and novelties, and confections.
• Cosmetic and grooming items and services in excess of those for which payment is made under Medicaid or Medicare.
• Personal clothing.
• Personal reading materials.
• Gifts purchased on behalf of a resident.
• Flowers and plants. Social events and entertainment offered that are not part of the activities program.
• Noncovered special care services, such as privately hired nurses or aides.
• Private room, except when therapeutically required (for example, isolation for infection control).
• Specially prepared or alternative food requested instead of the food generally prepared by the facility.

The facility must not charge a resident (or his/her representative) for any item or service not requested by the resident.