Form 3645, Monthly Medicaid Occupancy Report

Effective Date: 7/2011

Availability

PDF: 3645.pdf

Instructions

Updated: 7/2011

DADS Rules and Policies for Medicaid Bed Allocations

www.dads.state.tx.us/providers/NF/bedallocation.html.

Methods for Submitting Form 3645

Form 3645 may be submitted by three different methods:
  1. Complete and submit the form online;
  2. Print a hard copy of Form 3645 from the DADS website; or
  3. Complete the form and submit via mail or fax.

Online Submission of Form 3645

An electronic version of the form is online at: www.dads.state.tx.us/providers/reports/occupancy/occupancyreportform.cfm and can be bookmarked or added to the "Favorites" folder for future access. Complete and submit the form according to the instructions below. Print a copy of the form before clicking "Submit" and maintain a copy for your records. A confirmation notice will be sent after the form is submitted. Print a copy of the confirmation notice and maintain a copy for your records.

Note: If submitting forms for more than one facility, click on Return to Occupancy Reports; select the hyperlink in the second bullet, submitting an online version of the monthly report form; and complete the form for the next facility. Do not use the cut and paste feature or any other shortcut to complete multiple forms.

If you have questions about completing and submitting the form, contact the Facility Certification staff at 512-438-2630 to request assistance.

Fax Submission of Form 3645

Print a hard copy of the form from the DADS website and submit it by faxing the completed form to 512-438-2730. Complete the form according to the instructions below and retain a copy of the form.

Mail Submission of Form 3645

Print a hard copy of the form from the DADS website and submit it by mail to:

Department of Aging and Disability Services
Regulatory Services Division
Mail Code E-342
P.O. Box 149030
Austin, TX 78714-9030

Form Completion Instructions: Read Prior to Completing the Form

Identification Information

Type or print the facility's name, identification (ID) number, address and phone number into the appropriate fields as required.

Be certain that the number entered into the "Facility ID Number" field is the facility's six-digit state-issued ID number, not the facility's provider number issued by CMS, the National Provider Identification number, or any other number.

www.dads.state.tx.us/providers/NF/nf.pdf. The directory is organized alphabetically by county. Locate the county within which the facility is located and it will be listed alphabetically within that county. The facility ID number is listed in the middle column of the second line of each entry. Note: This directory also includes bed classification information about the facility. That information is important for completion of the next section of the form, Medicaid Bed Occupancy.

Select the month and year that is being reported by clicking on the blank field below the Month and Year heading, selecting the appropriate month and clicking on that month if the form is being completed online. Otherwise, type or print the month and year into the appropriate fields.

Medicaid Bed Occupancy

To calculate the Medicaid bed occupancy, you must know the different classifications of beds in a nursing facility. The bed classifications include:

  • Licensed-only bed – A bed in a licensed nursing facility that has not been certified for compliance with the Medicare or Medicaid programs. Do not include licensed-only beds in the Medicaid bed occupancy calculation.
  • Medicaid-certified bed – A bed that DADS has certified for compliance with the Medicaid program.
  • Medicare-certified bed – A bed that DADS has certified for compliance with the Medicare program. Do not count Medicare-certified only beds in the Medicaid bed occupancy calculation.
  • Dually certified bed – A bed that DADS has certified for compliance with both the Medicare and Medicaid programs.
  • Spend-down Medicaid bed – A bed in a licensed nursing facility that is temporarily allocated for residents who have "spent down" to become eligible for Medicaid, but for whom no Medicaid bed is available. Do not include spend-down beds in the Medicaid bed occupancy calculation.

Complete this section of the form by reporting the total number of days each Medicaid-certified bed was occupied during the month. To calculate this number, you must know the correct total number of Medicaid-certified beds in the facility. That information can be obtained from the directory as described above. The classification of licensed beds is listed in the bottom left quadrant of the facility’s entry in the directory. The total number of Medicaid beds is calculated by adding the number of beds that are certified Medicaid only (listed as Title XIX in the directory), and the number of beds that are dually certified for both Medicare and Medicaid (listed as Title XVIII/XIX in the directory).

Note: This calculation should include every occupant of every Medicaid-certified bed, regardless of payment source for that resident. The calculation is not restricted to Medicaid recipients only. The calculation includes residents who are Medicaid recipients, Medicare recipients, private pay residents, etc., if they are in a Medicaid-certified bed. The only exceptions to this are spend-down Medicaid recipients who are occupying a temporarily certified spend-down Medicaid bed.

There are two methods of calculating the Medicaid bed occupancy for the previous month. Either method will yield the same result. The methods are:

  1. Count by Days – Maintain a record of the number of Medicaid-certified beds (including both Medicaid only and Medicare/Medicaid) that were occupied each day of the month. At the end of the month, add the number of Medicaid beds occupied each day and enter that total in the space on the form.
  2. Count by Beds – Maintain a record of the number of days each Medicaid-certified bed was occupied during the month. At the end of the month, add the number of days each Medicaid bed was occupied and enter the total in the space on the form.

Examples:
Below are two examples for calculating the Medicaid bed occupancy of a facility with a total of 16 Medicaid and dually certified beds in a 31-day month.

Example A—Count by Days
Day of the Month Beds Occupied on that Day
1 13
2 13
3 13
4 13
5 12
6 12
7 12
8 13
9 13
10 13
11 13
12 13
13 13
14 13
15 13
16 11
17 11
18 11
19 11
20 11
21 11
22 11
23 11
24 11
25 11
26 11
27 11
28 11
29 11
30 11
31 11
Total 368

Example B—Count by Beds
Bed Number of Days this Month the Bed Was Occupied
101 A 31
101 B 31
102 A 28
102 B 31
103 A 31
103 B 15
104 A 15
104 B 31
105 A 31
105 B 31
106 A 31
106 B 0
107 A 31
107 B 31
108 A 0
108 B 0
Total 368

Medicaid Recipients

Enter the total number of residents receiving Medicaid benefits on the last day of the month in this space. Include individuals who have been determined Medicaid eligible and those that have applied for Medicaid eligibility and their eligibility status is pending.

Licensed Beds Available for Occupancy

Enter the total number of licensed beds set up, equipped with a nurse-call device and other required equipment and available for current or immediate occupancy on the last day of the month in this space, regardless of whether the bed is occupied or not. Do not include beds not currently in service due to rooms being converted to office space, physical therapy rooms or other uses, beds in multi-bed rooms that are not available to be occupied because the room has been converted to private occupancy or beds that have been taken out of service for any other reason.

Facility Census

Enter the total census of the entire licensed facility on the last day of the month in this space. This number is not restricted only to the occupancy of certified Medicaid beds. It includes all residents of all beds in the facility on the last date of the month, regardless of payor source.

Children in Facility

Enter the total number of residents under age 22 residing in the entire licensed facility on the last day of the month in this space. Facility residents age 21 and under should be included in the Medicaid occupancy calculation previously described if they reside in a certified Medicaid bed, but they should also be included in this separate calculation, regardless of the type of bed they occupy in the licensed facility.

Signatures

The nursing facility administrator must print and sign his or her name and date the form. If an individual other than the administrator completed the form, that person also must print and sign his or her name and date the form. If the form is being completed online, the signatures may be typed into the signature field.

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