Nursing Home and Assisted Living Pre-Admission Screening

1. Nursing Home and Assisted Living Pre-Admission Screening Department of Medical Assistance Services www.cns.state.va.us/dmas

2. Goal • To provide information to Nursing Home and Assisted Living Pre-Admission Screening providers regarding Medicaid policies and procedures for pre-admission screenings.

3. Objectives Participants will have a better under- standing of the pre-admission screening process which will: • Reduce the time between the submission of pre-admission screening packages and actual reimbursement to providers for services. • Allow screening teams to have a better understanding of the services that can be authorized

4. Objectives Participants should be able to properly submit pre-admission screening packages and resolve error messages including: • Eliminating common errors up front • Reducing the number of error letters generated to the pre-admission screening teams

5. Medicaid Program History • Authorized as part of the SSA Amendments of 1965, signed into law July 30, 1965. • Medicaid grew out of and replaced two federal grants to states programs.

6. Medicaid Program History • Maximum federal expenditures were expected to be $238 million above the programs already in place ($1.3 billion) • The $238 million was exceeded in the first 6 months of the program with only 6 states implementing programs

7. Medicaid Program History • By 1998, the Medicaid program nationally provided services to approximately 40.6 million low income individuals at a cost of $169 billion

8. Medicaid Program History • The Virginia Medicaid program was established in 1969 • Originally administered by the Virginia Department of Health; DMAS was created and designated as the single state agency charged with administering the program in March 1985

9. Medicaid Program History • The Center for Medicare and Medicaid Services (CMS) is the federal oversight agency for the Medicaid program. • The CMS central office is located in Baltimore and Virginia’s regional office is located in Philadelphia.

10. Medicaid Budget • DMAS expenditures for fiscal year 2000 were $2,808,983,547 • 51.85% of Medicaid expenditures comes from federal funds (“federal financial participation or FFP”) • Medicaid is the primary funding source for long-term care services in Virginia

11. Inpatient Hospital Services Emergency Hospital Services Outpatient Hospital Services Nursing Facility Care Rural Health Clinic Services Federally Qualified Health Center Clinic Services Lab and X-Ray Services Physician Services Home Health Services EPSDT Family Planning Nurse-Midwife Services Transportation Medicare Premiums (Part A) - Hospital; (Part B) - Supplemental Ins. For Categorically Needy Mandatory Services Provided Through Medicaid

12. Other Clinic Services Skilled Nursing Facility Services for Individuals under 21 years of age Podiatrist Services Optometrist Services Clinical Psychologist Services Certified Pediatric Nurse and Family Nurse Practitioner Services Home Health: PT, OT, and Speech Therapy Dental Services for Persons under 21 Physical, Speech & Occupational Therapies Prescribed Drugs Case Management Services Prosthetics Mental Health Services Mental Health Clinic Services Hospice Services Medicare Part B Premiums for the Medically Needy Optional Services Provided Through Medicaid

13. Who is Eligible for Medicaid? • Categorical Eligibility • Aged, blind, and • disabled • Families with • children • Recipients of • cash assistance • Pregnant women • and children • Low income • Medicare • beneficiaries Financial Eligibility After meet a category must meet income and asset guidelines, as well as non-financial criteria.

14. Medicaid Funded Long Term Care • In fiscal year 2000, the Virginia Medicaid Agency paid over a billion dollarsfor individuals receiving long-term care services • 44,100 individuals received long-term care services from Medicaid funded programs in fiscal year 2000

15. Long-Term Care Services Defined • Institutional Services • Nursing Facility • Intermediate Care Facilities for the Mentally Retarded (ICF/MR) • Community Based Services • Waivers • Program of All-Inclusive Care For the Elderly (PACE)

16. Eligibility for Long-Term Care Services • To be eligible for Medicaid-funded long-term care services individuals must : • Qualify for Medicaid* • Meet specified long-term care criteria according to a standardized long-term care assessment instrument • Uniform Assessment Instrument (UAI) for nursing facility level of care • Level of Functioning (LOF) Survey for ICF/MR level of care

17. Qualifying for Medicaid • Individuals who are Medicaid eligible at the time of application for LTC services are not automatically eligible for LTC services if they meet the functional assessment. • The local DSS must assess the individual’s eligibility for Medicaid (LTC) and calculate a patient pay.Everyone must have a calculation, not everyone has a patient pay.

18. Screening Process

19. The Pre-Admission Screening Process Who, What, Where, When, How?

20. Medicaid Eligibility for LTC Services • To be eligible for Medicaid funded long-term care services (whether they are institutional or community based,) the following requirements must be met for each individual: • Quality for Medicaid; • Meet specified long term care criteria according to standardized long term care assessment instrument (currently we use the UAI).

21. What is Pre-Admission Screening? • According to the Code of Virginia defines preadmission screening as the following: • “§32.1-330. Preadmission screening required. All individuals who will be eligible for community or institutional long-term care services as defined in the state plan for medical assistance shall be evaluated to determine their need for nursing facility services as defined in that plan.

22. What is Pre-Admission Screening? • The Department shall require a preadmission screening of all individuals who, at the time of application for admission to a certified nursing facility as defined in §32.1-123, are eligible for medical assistance or will become eligible within six months following admission. For community-based screening, the screening team shall consist of a nurse, social worker and physician who are employees of the Department of Health or the local department of social services. For institutional screening, the Department shall contract with acute care hospitals.”

23. What is Pre-Admission Screening? • The Code of Federal Regulations defines preadmission screening as the following: • “§441.302 State Assurances. • (b) Financial accountability – The agency will assure financial accountability for funds expended for home and community-based services… • (c) Evaluation of need. Assurance that the Agency will provide for the following:

24. What is Pre-Admission Screening? • (1) Initial evaluation. An evaluation of the need for the level of care provided in a hospital, a nursing facility, or an ICR/MR when there is a reasonable indication that a recipient might need the services in the near future (that is, a month or less) unless he or she receives home or community-based services. For purposes of this section, “evaluation” means a review of an individual recipient’s condition to determine—

25. What is Pre-Admission Screening? • (i) If the recipient requires the level of care provided in a hospital as defined in §440-40 of this subchapter, a NF as defined in section 1919(a) of the Act, or an ICF/MR as defined by §440.150 of this subchapter; and • (ii)That the recipient, but for the provision of waiver services, would otherwise be institutionalized in such a facility.

26. What is Pre-Admission Screening? • (d) Alternatives. Assurance that when a recipient is determined to be likely to require the level of care provided in an SNF, ICF, or ICF/MR, the recipient or his or her legal representative will be— • (1) Informed of any feasible alternatives available under the waiver; and • (2) Given the choice of either institutional or home and community-based services.”

27. Why do we do pre-admission screenings? • To assure appropriate levels of care (i.e. home care or nursing facility care) • To assure appropriate service provision (i.e. specific services to meet individual needs)

28. Who does the pre-admission screening? • Medicaid agency has responsibility to safeguard against unnecessary or inappropriate use of Medicaid services – federal requirement (42 CFR 456.3) • Local pre-admission screening committees (composed of local health departments, local departments of social services and acute care facilities).

29. Who needs to be screened? • Individuals in the community or acute care/rehab hospitals who are, • a) Already Medicaid eligible, or • b) Expected to become eligible for Medicaid within 180-days of admission to the nursing facility • Nursing Facilities are responsible for making sure that they 180-day requirements will be fulfilled.

30. Who needs to be screened? • Nursing Facilities are under no obligation to admit recipients who have not been pre-screened prior to admission. • Individuals entering a nursing facility for a short-term rehabilitation stay are subject to pre-admission screening and should be screened prior to admission. • Pre-admission screening is required regardless of the anticipated length of stay of an individual if Medicaid payment is expected.

31. When does a screening need to be done? • Prior to admission to a nursing facility if you expect Medicaid to provide payment. NOTE: Individuals must be screened by the pre-admission screening team and deemed eligible for services. A complete assessment must be made before screeners can determine service options.

32. Pre-Admission Screening • Nursing Home Pre-Admission Screening. The Commonwealth of Virginia requires that all individuals who currently Medicaid eligible or will become Medicaid eligible within the first 180 days of admission to nursing facility or community based care waiver service, be screened. The purpose of pre-admission screening is to ensure that the individual meet the established criteria for placement either into a nursing facility or waiver service. One of the goals is always to place individuals with the needed services in the least restrictive environment.

33. Pre-Admission Screening • For hospitalized recipients, the acute care hospital staff completes the pre-admission screening process. For community-based recipients, it is a joint effort between the local departments of social services and the local health departments.

34. Pre-Admission Screening • For recipients with mental health, mental retardation, or related conditions, there is an additional screening that must take place prior to service authorization. This is referred to a Level II screening for nursing facility placement and the 101 process for access to waiver services. It is the responsibility of the pre-admission screening teams to make the appropriate referrals for completion of the additional mental health, mental retardation or related condition portion.

35. Questions and Answers Some Frequently Asked Questions submitted by Pre-Admission Screening Teams

36. Question? • Can an individual receive services under more than one Waiver at one time? RESPONSE: Individuals can be authorized to receive services under only one Home and Community-Based Care Waiver at any given time.

37. Question? • On page 4, Section 2 of the UAI under ambulation there is a question about walking. If a worker marks ‘no’ and then across the page marks ‘is not performed’, the UAI is sent back, as apparently this is not correct. We need clarification on this question. RESPONSE: If you mark ‘no’ there is no need to complete any of the other questions on the form.

38. Question? • Can skilled units of acute care hospitals complete a nursing home pre-admission screening? RESPONSE: Skilled units of acute care hospitals are not authorized to complete nursing home pre-admission screenings for any type of service. The acute care hospital must complete the pre-admission screening PRIOR to discharge to the skilled unit of the hospital. The skilled unit of the hospital is the same as any other nursing facility and recipients in that unit are subject to the same rules and regulations.

39. Question? • Can skilled units of acute care hospitals complete a nursing home pre-admission screening? RESPONSE: Acute care social work staff or discharge planners may not complete the pre-admission screening forms for individuals located in the skilled units of the hospitals once admission has taken place.

40. Question? • What about recipients who are currently in a VA Hospital? Are they subject to pre-admission screening? RESPONSE: Recipient admitted directly from a VA Hospital to a directly to a nursing facility is not subject to the normal pre-admission screening process. The nursing facility can accept the discharge information from the VA Hospital in place of the pre-admission screening.

41. Question? • What about recipients who are currently in a VA Hospital? Are they subject to pre-admission screening in order to receive waiver services? RESPONSE: For Home and Community Based Care recipients the local community screening team (consisting of the local department of social services and the local health department) is responsible for authorization of any waiver service.

42. Question? • Do pre-admission screening teams need to complete a decision letter for authorized services? RESPONSE: Yes, recipient must be given a decision letter that includes appeal information for any decision made by the pre-admission screening teams.

43. Question? • Who can sign for the doctor on the pre-admission screening forms? RESPONSE: Only the reviewing physician may sign and date his signature during the completion of a pre-admission screening. Nurse or social worker signatures for the physician are not permitted. The use of rubber stamps for signatures or dating is not permitted.

44. Question? • Can the pre-admission screening teams determine the number of hours a recipient receives under the waivered services? RESPONSE: NO, the pre-admission screening teams are not permitted to determine the number of hours a recipient may receive under a waivered service.

45. Question? • What about Hospice Services? RESPONSE: A recipient may receive Medicaid Hospice benefits and personal care services under the Elderly and Disabled Waiver or Nursing Facility Services at the same time. For Home and Community-Based Care Waivered Services, pre-admission screening is required. The Community-Based Care provider will coordinate services with the Hospice provider.

46. Question? • What about children? Do they have to be screened? RESPONSE: Children are subject to the same rules and regulations regarding pre-admission screening as adults. A pre-admission screening team must consider the risks and place the child in the most appropriate waivered service or an appropriate nursing facility that can address the needs of a child.

47. Question? • When is a DMAS-101A and DMAS-101B completed for waiver recipients? RESPONSE: Upon completion of the UAI Assessment for a Home and Community-Based Care Waiver Service, if there is a diagnosis of Mental Illness, Mental Retardation or a Related Condition, then a referral for a DMAS-101A must be made to the local Community Services Board (CSB). The local CSB will then complete the DMAS-101B form and will return the completed package back to the originating screening team.

48. Question? • When is a DMAS-101A and DMAS-101B completed for waiver recipients? RESPONSE: No service authorization can be made prior to the completion of both the DMAS 101-A and DMAS 101-B. Depending on the outcome of the completed DMAS 101-B, the screening team needs to review and authorize the most appropriate waiver. If you have questions, please call the Waiver Services Unit at (804) 786-1465.

49. Question? • When is a MI/MR Level I and Level II completed for nursing facility residents? RESPONSE: The process is very different from referrals for a MI/MR Level I and Level II screening for nursing facility placement. All referrals for nursing facility placement must be made to the DMHMRSAS Contractor. The current contractor is Dual Diagnosis Management, LLC. They may be reached by contacting the project manager at 1-877-431-1388.

50. Question? • What about appeal rights? RESPONSE: Individuals wishing to appeal determinations made by the hospital or local screening committees should notify the Appeals Division, Department of Medical Assistance Services, in writing, of his or her desire to appeal within 30 days of the receipt of the Committee’s decision letter.