Sec. 10.67.06.12. Benefits — Long-Term Care Facility Services

A. An MCO shall provide to its enrollees medically necessary services in a chronic hospital, a chronic rehabilitation hospital, or a nursing facility for:

(1) The first 90 continuous days following the enrollee's admission; and

(2) Any days following the first 90 continuous days of an admission until the date the MCO has obtained the Department’s determination that the admission is medically necessary as specified in §C of this regulation.

B. Acute care services provided within the first 90 days following an enrollee's admission to a long-term care facility do not constitute a break in calculating the 90 continuous day requirement if the enrollee is discharged from the hospital back to the long-term care facility.

C. For any long-term care facility admission that is expected to result in a length of stay exceeding 90 days, an MCO or long-term care facility shall request a determination by the Department that the admission is medically necessary.

D. The Department’s determination as described in §C of this regulation is only applicable if the enrollee is still in the long-term care facility on the 91st day.

E. The Department shall render a determination with respect to the medical necessity of a stay in a nursing facility as specified in §C of this regulation within 3 business days of receipt of a complete application from the MCO.

F. A determination by the Department that the admission is medically necessary does not relieve the MCO of the obligation to pay for the admission through the day on which the determination is made.

G. An MCO shall use the Department’s criteria for determining medical necessity for the days described in §A(1) of this regulation.