Rule 5160-3-16.3 | Nursing facilities (NFs): private rooms.
(A) Medical necessity.
(1) A nursing facility (NF) operator shall provide private room accommodations, if available, for a medicaid eligible resident if the resident requires a private room due to medical necessity such as the need for infection control.
(2) Medicaid payment shall be considered payment in full, and no supplemental payment may be requested or accepted from a resident or from a resident's authorized representative or family.
(B) Semiprivate or ward accommodations unavailable.
(1) Medicaid shall not pay more for a private room than the current medicaid per diem rate the facility is receiving if semiprivate or ward accommodations are not available.
(2) Medicaid payment shall be considered payment in full, and no supplemental payment may be requested or accepted from a resident or from a resident's authorized representative or family.
(C) Supplemental payment.
If semiprivate or ward accommodations are available and are offered to a resident but the resident or the resident's representative or family member makes a written request for a private room, the private room shall be considered a non-covered service for which the facility may seek supplemental payment from the resident or from the resident's authorized representative or family. Such supplemental payment shall conform to all of the following:
(1) The supplemental payment amount shall represent no more than the difference between the charge to a private pay resident for a semiprivate room and the charge to a private pay resident for a private room; and
(2) The charge for the private room shall not include charges for services covered by medicaid, whether or not medicaid payment meets a NF operator's costs for the per diem services; and
(3) A NF operator shall detail both monthly and annual supplemental charges, if applicable, on a resident's statement of charges so that the additional cost of a private room is evident to the resident and to the resident's authorized representative and family; and
(4) The written request for a private room shall be kept in the resident's file; and
(5) The amount of any supplemental payment shall not be considered when calculating the resident's patient liability.
Last updated January 12, 2024 at 3:23 PM
Supplemental Information