Nursing Home and Assisted Living PreAdmission 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 Virginias 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
Mandatory Services Provided Through Medicaid

• 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

12
Optional Services Provided Through Medicaid

• 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

• 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

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 dollars for 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 individuals
  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 recipients condition to determine

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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.

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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.

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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.

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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 [phone].

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
  Committees decision letter.

51
Question?

• What about appeal rights?
• RESPONSE All decision letters must include the
  following statement You may appeal this
  decision by notifying, in writing, the Appeals
  Division, Department of Medical Assistance
  Assistance Services, 600 East Broad Street, Suite
  1300, Richmond, Virginia 23219. This written
  request for an appeal must be filed within thirty
  (30) days of the date of this notification.

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The UAI

• General Information to assist with completion of
  Pre-Admission Screening Packages

53
Records Retention

• All pre-admission screenings forms must be
  retained for a period of not less than five years
  from the date of the screening.

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General Information - UAI

• In an effort to reduce the time and labor
  involved in the screening and data entry of
  submitted pre-admission screening packages from
  providers, the Department of Medical Assistance
  Services has instituted a few changes to the
  process.

55
General Information - UAI

• First, all completed pre-admission screening
  packages must be submitted directly to First
  Health Services for processing. The address is
• First Health Services
• Post Office Box 85083
• Richmond, Virginia 23285-5083

56
General Information - UAI

• Secondly, the following information must be
  included with all pre-admission screenings
  submitted to First Health Services
• In Chapter I of the Virginia Medicaid Nursing
  Home Pre-Admission Screening Manual, page 7, page
  revision date 3-15-94, it states A 100.00 fee
  per pre-admission screening will be paid to acute
  care hospitals, private psychiatric hospitals,
  ASOs, and the local Nursing Home Pre-Admission
  Screening Committees.

57
General Information - UAI

• For the local committees, the local health
  department will receive 69.00 per screening and
  the local social services departments will
  receive 31.00 per screening in which they
  participate. The same fee per screening is used
  statewide and represents compensation for all
  services rendered and completion of the forms
  required to authorize Medicaid payment for
  nursing facility placement or community based
  long term care waiver services.

58
General Information - UAI

• Each pre-admission screening package sent to
  DMAS for reimbursement is reviewed for accuracy,
  completeness and adherence to DMAS policies and
  procedures. An incomplete, illegible, or
  inaccurate package will not be processed for
  payment. Reimbursement will be made only a
  screening which includes all the required forms
  that have been correctly completed and submitted
  to the Department of Medical Assistance
  Services.

59
General Information - UAI

• Further it states,
• Nursing home pre-admission screening forms must
  be submitted to the Department of Medical
  Assistance Services within 30 days of the
  assessment date to assure prompt reimbursement.
  To expedite the reimbursement process for
  pre-admission screening, submit the pre-admission
  screening package with the contents in the
  following order

60
General Information - UAI

• DMAS-96 Authorization of Services Form
• UAI form (all 12 pages)
• DMAS-113A and DMAS-113Bforms (if applicable)
• DMAS-95 MI/MR Supplemental form (if applicable)
• DMAS-101A and DMAS-101B forms (if applicable)
• DMAS-97 form (Waiver Services Plan of Care)
• DMAS-300 form (if applicable)
• DMAS-20 form (consent to exchange information)
• The Decision Letter
• All other forms

61
General Information - UAI

• No additional reimbursement will be paid for
  updating the assessment during the same
  pre-admission screening process. For example, if
  an individual is in an acute care hospital and a
  nursing facility pre-admission screening is
  required, the hospital will be reimbursed for
  only one pre-admission screening per hospital
  admission.

62
General Information - UAI

• There will be no reimbursement for screenings
  received by the Department of Medical Assistance
  Services 12 months or more after the date of the
  completion of the screening.
• No reimbursement for completed pre-admission
  screenings will be made for screenings completed
  by non-approved DMAS pre-admission screening
  teams.

63
The UAI

• Specific Information to assist with completion of
  Pre-Admission Screening Packages

64
Specific Information - UAI

• Page One - Date portion of form is required.
• Section Identification/Background (page 1)
• Required items for completion are
• Client Name
• Client Social Security Number
• Address (which includes street, city, state and
  zip)
• City/County Code

65
Specific Information - UAI

• Section Demographics (page 1)
• Required items for completion are
• Birthdate (includes month, date and year)
• Sex
• Marital Status
• Race
• Communication of Needs

66
Specific Information - UAI

• Section - Financial Resources (page 2)
• Required items for completion are
• Medicare Number
• Medicaid Number (must include number or
  pending)

67
Specific Information - UAI

• Section Physical Environment (page 3)
• Required items for completion are
• Must complete the appropriate section under the
  following questions
• Where do you usually live?
• Does anyone live with you?

68
Specific Information - UAI

• Section Function Status (page 4)
• Required items for completion are
• This entire page must be completed. Both
  sections must be completed.

69
Specific Information - UAI

• Section Diagnosis and Medication Profile (page
  5)
• Required items for completion are
• Diagnosis Codes/Diagnosis must be present on the
  UAI form.
• NOTE DMAS will not accept diagnosis information
  on any other type of record such as hospital
  discharge forms.

70
Specific Information - UAI

• Total Number of Medications must be answered
• How do you take your medicine(s) must be answered
• NOTE DMAS will not accept medication information
  on any other type of record such as hospital
  discharge forms.

71
Specific Information - UAI

• Section Physical Status (page 6)
• Required items for completion are
• Joint Motion section must be completed
• Fractures/Dislocations must be completed
• Missing limbs must be completed
• Paralysis/Paresis must be completed

72
Specific Information - UAI

• Section Nutrition (page 6)
• Required items for completion are
• Height
• Weight
• Recent Weight Gain/Loss (indicate which and
  amount)

73
Specific Information - UAI

• Section Current Medical Services (page 7)
• Required items for completion are
• Questions related to Therapies must be completed
• Questions related to Medical Procedures must be
  completed
• Question related pressure ulcers must be
  completed

74
Specific Information - UAI

• Section Medical/Nursing Needs (page 7)
• Required items for completion are
• Questions must be completed
• Narrative portion must be completed

75
Specific Information - UAI

• Section Psycho-Social Assessment (page 8)
• Required items for completion are
• Orientation portion must be completed
• Behavior Pattern must be completed

76
Specific Information - UAI

• Section Assessment Summary (page 11)
• Required items for completion are
• Questions must be completed related to Caregiver
  Assessment

77
Specific Information - UAI

• Section Client Case Summary (page 12)
• Required items for completion are
• Narrative portion must be completed

78
Specific Information - UAI

• Section Unmet Needs (page 12)
• Required items for completion are
• Questions must be completed

79
Specific Information - UAI

• Section Assessment completed by (page 12)
• Required items for completion are
• Section must be completed

80
Specific Information - UAI

• Outlined above are specific items that must be
  completed on each UAI that is submitted to DMAS
  for reimbursement. However, DMAS must stress
  that this form must be completed in its entirety
  or an error letter back to the provider seeking
  correction will be sent.

81
Assisted Living

• General Information Regarding Authorizations for
  Assisted Living Services

82
Assisted Living Screenings

• Such as local health departments, local
  departments of social services, acute care
  hospitals, local area agencies on aging, local
  community services boards, AIDS service
  organizations and some private mental hospitals
  as well as private physicians. Each individual
  or provide agency must have contract with DMAS to
  perform these screenings. The assisted living
  screenings can be performed individually, meaning
  they are not a joint effort across provider
  agencies.

83
Who Must be Assessed?

• All residents and applicants to Assisted Living
  Facilities regardless of the payment source or
  length of stay.
• New admissions to Assisted Living Facilities must
  be assessed prior to admission.

84
Who completes the assessments for public pay
individuals?

• Public Case Managers employed by the local
  departments of health, social services, area
  agencies on aging, centers for independent
  living, or community services boards or
• Other qualified assessors including acute care
  hospitals, state mental health and mental
  retardation facilities.

85
Who completes the assessments for private pay
individuals?

• Qualified staff of the ALF with documented
  training on completion of the UAI or
• Independent private physicians or upon request
• By a public case manager or qualified assessor.

86
What is to be completed for public pay
individuals?

• The short assessment (Part A) of the UAI is
  completed on individuals meeting Residential
  Living criteria. Completion of the short
  assessment includes completion of the Medication
  Administration and Behavior patterns of the UAI.
• The full assessment (Part B) of the UAI is
  completed on individuals meeting Regular Assisted
  Living Criteria. The full assessment includes
  all 12 pages of the UAI.

87
What is completed for private pay individuals?

• An alternate one-page assessment form has been
  developed for private pay residents.
• Collects only information needed to document the
  level of care.
• Common definitions developed for the UAI is used.

88
Who pays for Assessments?

• For private pay, costs are anticipated to be
  minimal. Upon request, public case managers or
  other qualified assessors may complete for a fee.
  Payment is the responsibility of the resident.
• For public pay, DMAS will reimburse 25 for a
  short assessment and 100 for a full assessment.

89
What is the responsibility of the Assessment
Agency?

• To determine if the individual to be assessed is
  already AG or has made application for an AG.
• To complete the assessment process within two
  weeks of referral. The following forms must be
  completed DMAS-20 Consent to Exchange
  Information Form UAI, DMAS-96.
• To determine that ALF placement is appropriate.

90
What is the responsibility of the Assessment
Agency?

• To determine there are no prohibited conditions
  present.
• To determine appropriate level of care and
  authorize service on the DMAS-96 prepare
  authorization letter to the individual.
• Contact the ALF of choice (determine if the ALF
  license matches the individual authorization and
  can meet the individuals needs.)

91
What is the responsibility of the Assessment
Agency?

• Submit paperwork to all entities as directed.
• Refer individual for psychiatric/psychological,
  if appropriate.
• Plan for required 12 month reassessment (make
  referrals if appropriate).

92
What are prohibited conditions?

• Ventilator Dependency
• Dermal Ulcers Stages III and IV
• IV Therapy or IV Injections
• Communicable Airborne Infectious Disease
• Psychotropic Medications without appropriate
  diagnosis and treatment plans
• NG/G Tubes

93
What are prohibited conditions?

• Individuals who are imminent physical threat or
  danger to self or others
• Individuals requiring continuous nursing care (7
  days per week/24 hours per day)
• Individuals whose physician certifies placement
  is no longer appropriate
• Individuals who require maximum physical
  assistance (total dependence in 4 ADLs)

94
What about Changes in Level of Care Assessments?

• Completed by all entities qualified to perform
  initial assessments.
• Performed only when permanent changes in level of
  care indicated. Temporary changes are less than
  30 days.
• Follow same assessment process as initial
  assessment.
• Payment tied to completion of the short versus
  full assessment.

95
When is a new assessment not needed?

• If there is a current assessment completed within
  the last 12 months and there has been no change
  in level of care, then a new assessment is not
  needed for
• Lapse in financial eligibility
• Transfer from one ALF to another ALF
• Discharged back to the ALF from the hospital

96
Who is subject to reassessment?

• All public pay ALF residents must receive a 12
  month reassessment visit
• Hospital, State MH/MR facilities and Physicians
  must send a copy of the UAI, DMAS-96 and
  Reassessment date to the Adult Services
  Supervisor of the local DSS where the ALF
  resident will reside

97
Who is subject to reassessment?

• LDSS where the AG application is made is
  responsible for initial assessment LDSS where
  individual resides following ALF placement is
  responsible for 12 month reassessment (if there
  is no other public agency willing to complete the
  reassessment)
• Original assessor responsible for 12 month
  reassessment unless referral is accepted by
  another assessor
• Residents receiving targeted MH/MR case
  management services must be reassessed by that
  case management agency (no additional
  reimbursement allowed)

98
If the level of care changes, what happens to the
12-month reassessment process?

• Treat as a change in level of care, not a 12
  month reassessment
• Complete the DMAS-96 and follow previous
  procedures for authorization and payment. This
  only applies to changes from Residential Living
  to Regular Assisted Living.
• Do not complete the ALF Eligibility Communication
  Document or submit a HCFA-1500 claim form.

99
What is the reimbursement?

• 25 for completion of short 12-month reassessment
  only. (Record the CPT/HCPCS Code (Z8577) on the
  HCFA-1500 Invoice.)
• 75 for completion of the full 12 month
  reassessment only. (Record the CPT/HCPCS Code
  (Z8578) on the HCFA-1500 Invoice.)

100
What about appeal rights?

• Individual does not meet minimum criteria for
  public payment for ALF care (Residential Living
  Criteria) Direct appeals to DSS.
• Individual does not meet criteria for regular
  assisted living services Direct appeals to DMAS.

101
Why is it required?

• To assure appropriate placement
• To assure appropriate payment
• To provide basic monitoring of continued
  appropriate placement and payment

102
Case Management Services

• General Information Regarding Case Management
  Services for Assisted Living Residents

103
Who can provide ALF Case Management Services?

• LDSSs, AAAs, CILs, CSBs, and local health
  departments with staff that meet the knowledge,
  skills and abilities (KSAs) of a case manager
• Hospitals, State MH/MR facilities, and physicians
  cannot perform ALF case management services
  (limited to initial assessments and changes in
  level of care assessments only.)

104
What is Medicaid funded ALF Case Management
Services?

• There are currently two types of activities
  reimbursed as Medicaid ALF case management
  services
• 12 Month Reassessment Only
• Ongoing Targeted Case Management Services

105
What are the criteria the resident must meet to
receive ALF Case Management Services?

• Require coordination of multiple services, and/or
• Has some problem which must be addressed to
  ensure residents health and welfare, AND
• Is not able to have other support available to
  assist in coordination or access of services or
  problem resolution

106
What are the responsibilities of Targeted Case
Management providers?

• Completion of 12 month reassessment (considered
  on of the quarterly visits)
• Any change in level of care assessment, as
  appropriate
• Development of a plan of care that addresses the
  needs on the UAI and maintain a log of contacts
  (provide copy care plan to resident, family
  ALF)

107
What are the responsibilities of Targeted Case
Management providers?

• Monitor the ALF Individualized Service Plan (ISP)
  and other written communication concerning the
  care needs of the resident
• Quarterly visits with the resident and/or his/her
  representative to evaluate the residents
  condition, service needs, appropriate service
  placement and satisfaction with care

108
What are the responsibilities of Targeted Case
Management providers?

• Contact for ALF, family and other service
  providers to coordinate and problem solve
• Assist with discharge, as necessary
• Implement and monitor the plan of care

109
What are the differences between the Case
Managers plan of care and ALF Individualized
Service Plan?

• Plan of Care Case Manager addresses needs that
  cannot be met by the ALF
• Individualized Service Plan ALF addresses needs
  that are set by licensing regulations
• Do not send a copy of the plan of care to DMAS.
  The plan of care will be reviewed during DMAS
  onsite visits

110
What is the DMAS reimbursement rate for ongoing
Targeted Case Management?

• 75 per quarter (12 month reassessment is
  included in this reimbursement)
• Record CPT/HCPCS code Z8574 on HCFA-1500 Invoice
• Case Management services may not be billed for
  same individual by any more than one type of case
  management provider

111
Are there other Medicaid-funded Case Management
Services?

• Case Management for Elderly Virginians
• Case Management for Mental Health/Mental
  Retardation

112
Services offered by the Long Term Care Division

• Specific information regarding the services
  offered through the Long Term Care Division

113
Assisted Living Services

• A recipient may qualify for the residential
  living program by meeting one of the following
  criteria
• Rated dependent in only 1 of 7 activities of
  daily living (ADLs) OR
• Rated dependent in 1 or more of 4 selected
  instrumental activities of daily living (IADLs)
  OR
• Rated dependent in medication administration

114
Assisted Living Services

• A recipient may qualify for the regular assisted
  living program by meeting one of the following
  criteria
• Rated dependent in 2 or more of 7 ADLs OR
• Rated dependent in behavior pattern

115
Assisted Living Services

• The criteria for AG and an individual must meet
  all of the following criteria to qualify are
• Be over 65, or be disabled
• Reside in a licensed assisted living facility
• Be a citizen of the United States
• Have income that is within the allowable limits
• Have limited resources
• And have been assessed and determined to need
  care in an assisted living facility.

116
Assisted Living Services

• A recipient may qualify for case management
  services by meeting one of the following
  criteria
• Require coordination of multiple services AND/OR
• Has some problem which must be addressed to
  ensure residents health and welfare AND
• Is not able to have other support available to
  assist in coordination or access of services or
  problem resolution

117
Nursing Facility Services

• A recipient may qualify for nursing facility
  level of care by meeting one of the following
  criteria
• Dependent in 2 to 4 ADLs, Plus semi-dependent or
  dependent in behavior and orientation, Plus
  semi-dependent in joint motion or semi-dependent
  in medication administration OR
• Dependent in 5 to 7 ADLs and dependent in
  mobility OR
• Dependent in 2 to 7 ADLs, Plus dependent in
  behavior and orientation AND
• Have medical nursing needs

118
PACE Services

• The criteria for the PACE program are as follows
• Be at least 55 years of age AND reside in a PACE
  providers service area AND
• Determined eligible for nursing facility care
  AND
• Be screened and assessed by the PACE team
• Agree to the terms and conditions of
  participation AND
• Have a safe plan of care

119
PACE Services

• Services offered under this waiver are
• Adult Day Health Care
• Personal Care
• Private Duty Nursing
• Nursing Facility Care
• Prescribed Medications
• Outpatient Medical Services
• Primary or Specialty Care
• Hospital Patient Care

120
DME Services

• DMAS has a large number of DME providers through
  out the commonwealth. DMAS covers a vast array
  of products and supplies through our DME program.
  We cover everything from apnea monitors to
  bandages and incontinence supplies. And the list
  goes on to include nutritional supplements,
  traction equipment, walkers, wheelchair
  accessories and even wheelchairs.

121
DME Services

• DME and supplies are covered services available
  to the entire Medicaid population. DMAS may also
  cover DME services when any of the following
  criteria are met
• The recipient is under age 21 and the item or
  supply could be covered under the Virginia State
  Plan for Medical Assistance (the State Plan)
  through the Early and Periodic Screening,
  Diagnosis and Treatment Program (or EPSDT) OR
• The recipient is enrolled in the Technology
  Assisted Waiver OR
• The recipient is enrolled in the AIDS Waiver

122
Hospice Services

• Hospice uses the interdisciplinary team approach
  to treat individual recipients. Most of the time
  hospice recipients are provided care by
  volunteers and family members who have been
  trained to assist in the care in addition to the
  use of professional staff. Hospice teams address
  all aspects of care. Such as physical,
  emotional, spiritual, social and even the
  economic stresses that may arise during the final
  stages of illness and even during the bereavement
  portion.

123
Hospice Services

• Routine Home Care which is at home care that is
  not continuous
• Continuous Home Care which is at home care that
  is predominantly nursing care and is provided as
  short-term crisis care. There is a minimum of 8
  hours per day of care that must be provided in
  order to qualify for this category of care. A RN
  or LPN must provide for at least half the care
  required.

124
Hospice Services

• Inpatient Respite Care which is short term
  inpatient care provided in an approved facility
  (a freestanding hospice, hospital or nursing
  facility) to relieve the primary caregivers.
  There can be no more than 5 consecutive days of
  respite care allowed.
• General Inpatient Care which may be provided
  again in an approved facility. This category of
  service is usually for pain control or acute or
  chronic symptom management that can not be
  treated successfully in another setting.

125
Hospice Services

• The services offered under hospice consist of
• Nursing Care
• Home Health Aide and Homemaker Services
• Medical Social Services
• Physician Services
• Counseling Services
• Short term Inpatient Care
• Durable Medical Equipment and Supplies
• Drugs and Biologicals
• Rehabilitation Services

126
Home Health Services

• Home health services are available to all
  categorically and medically needy individuals
  determined to be eligible for Medical Assistance.
  As with all our services, home health services
  must be provided accordance with all applicable
  state and federal regulations and laws. They may
  not be of any less or greater duration, scope, or
  quality than that provided to recipients not
  receiving medical assistance from either the
  state or federal government. Hospice services do
  require prior authorization.

127
Home Health Services

• Covered services are as follows
• Nursing services
• Home health aide services
• Physical therapy services
• Occupational therapy services and
• Speech therapy services

128
Home Health Services

• The recipient is unable to leave home without
  assistance of others or the use of special
  equipment
• The recipient has a mental or emotional problem
  which is manifested in part by refusal to leave
  his or her home environment or is such a nature
  that it would be not considered safe for him or
  her to leave home unattended
• The recipient is ordered by the physician to
  restrict his or her activity due to a weakened
  condition (for example, following surgery or
  heart disease of such severity that stress and
  physical activity must be avoided)
• The recipient has an active communicable disease,
  and the physician restricts the recipient to
  prevent exposing others to the disease

129
Rehab Services

• DMAS currently offers both inpatient and
  outpatient rehabilitation services. First, lets
  discuss outpatient rehabilitation services. The
  outpatient program was begin in 1978 and offers
  physical therapy, occupational therapy and
  speech-language pathology services. Outpatient
  rehab may be provided in hospitals, nursing
  facilities, rehabilitation hospitals,
  rehabilitation agencies, home health agencies and
  public schools.

130
Rehab Services

• The intensive rehabilitation program was
  implemented in 1986 to provide comprehensive
  rehab services. The services include
• Rehabilitation nursing
• Physical therapy
• Occupational therapy
• Cognitive therapy
• Speech-language pathology
• Social work services
• Psychology
• Therapeutic recreation
• Durable medical equipment

131
Waiver Services

• Waivers are optional programs that afford states
  the flexibility to develop and implement
  alternatives to institutionalization. The cost
  to Medicaid for provision of services in the
  community can be no higher than the cost to
  Medicaid for the same service in an institution.

132
AIDS/HIV Waiver

• Under the AIDS/HIV Waiver the individual must
• Diagnosis of AIDS or ARC AND
• Documentation that the individual is experiencing
  medical and functional symptoms associated with
  AIDS or ARC, which would require nursing facility
  or hospital care, AND
• Meet nursing facility screening requirements.

133
AIDS/HIV Waiver

• Under the AIDS/HIV Waiver an individual may
  receive the following services
• Case Management
• Respite Care
• Private Duty Nursing
• Personal Care
• Nutritional Supplements

134
CDPAS Waiver

• Under the Consumer-Directed Personal Attendant
  Services Waiver a recipient must meet the
  following criteria for authorization
• Dependent in 2 to 4 ADLs, PLUS semi-dependent in
  joint motion or semi-dependent in medication
  administration OR
• Dependent in 4 ADLs, PLUS dependent in mobility
  OR
• Dependent in 2-7 ADLs, PLUS dependent in
  mobility AND
• Have medical nursing needs AND
• Must be at imminent risk of nursing facility
  placement

135
CDPAS Waiver

• Services offered under this waiver are
• Personal Attendant Services
• Individuals seeking placement into the CDPAS
  program must be free of cognitive deficits.

136
Elderly Disabled Waiver

• Under the Elderly and Disabled Waiver a recipient
  must meet the following criteria for
  authorization
• Dependent in 2 to 4 ADLs, PLUS semi-dependent or
  dependent in behavior and orientation, PLUS
  semi-dependent in joint motion or semi-dependent
  in medication administration OR
• Dependent in 4 ADLs, PLUS dependent in mobility
  OR
• Dependent in 2-7 ADLs, PLUS dependent in
  mobility, PLUS dependent in behavior and
  orientation AND
• Have medical nursing needs AND
• Must be at imminent risk of nursing facility
  placement

137
Elderly Disabled Waiver

• Services offered under this waiver are
• Personal Care
• Respite Care
• Adult Day Health Care

138
IFDDS Waiver

• Under the Individuals and Families Developmental
  Disabilities Waiver a recipient must meet the
  following criteria for authorization
• The individual must be 6 years of age and older
  and meet the related conditions requirements of
  C.F.R. 435.1009, including autism and
• Not have a diagnosis of mental retardation as
  defined by the American Association of Mental
  Retardation (AAMR) 12 VAC 30-120-720

139
IFDDS Waiver

• Children under six years of age shall not be
  screened until three months prior to the month of
  their sixth birthday.
• Children under six years of age shall not be
  approved for waiver services until the month in
  which their sixth birthday occurs.

140
IFDDS Waiver

• Meet the level of care for admission to an
  Intermediate Care Facility for the Mentally
  Retarded (ICF/MR)
• The individuals income cannot exceed 300 of the
  SSI income level and cannot be on spend-down
• The income of parents is not deemed (42 C.F.R.
  435.217)

141
IFDDS Waiver

• The individual cannot be served in another waiver
• Earned income disregards for individuals who are
  employed
• Individuals can call DMAS at [phone] to
  receive a Request for Screening Form or download
  the form from the DMAS web site at
  www.cns.state.va.us/dmas/.

142
IFDDS Waiver

• Screenings are conducted by VDH Child Development
  Clinics 11 clinics throughout state - can find
  list at http///www.vahealth.org/specialchildren
  /cdsclinics.htm
• The LOF is the screening instrument used to
  determine if the individual meets criteria

143
IFDDS Waiver

• Services offered under this waiver are
• In Home Residential Support
• Supported Employment
• Environmental Modifications
• Respite Care
• Assistive Technology
• Day Support
• Therapeutic Consultation

144
IFDDS Waiver

• Services offered under this waiver are
• Personal Care
• Skilled Nursing
• Crisis Stabilization
• Companion Care
• Support Coordination
• Consumer Directed Attendant Care
• Consumer Directed Respite Care
• Personal Emergency Responses Systems (PERS)
• Family and Caregiver Training

145
MR Waiver

• Under the Mental Retardation Waiver a recipient
  must meet the following criteria for
  authorization
• Must meet criteria for ICF/MR AND
• Must have mental retardation or related
  condition OR under age 6 at developmental risk
  who requires a level of care in an ICF/MR. At
  age 6, the child must have mental retardation

146
MR Waiver

• Services offered under this waiver are
• Residential Support
• Supported Employment
• Environmental Modifications
• Respite Care
• Assistive Technology
• Day Support
• Therapeutic Consultation
• Personal Care
• Private Duty Nursing
• Crisis Stabilization

147
Tech Waiver

• Under the Technology Assisted Waiver a recipient
  must meet the following criteria for
  authorization
• Doctor must certify need for care AND
• Need substantial and ongoing skilled nursing
  care AND
• Care must be cost-effective AND
• Have a primary caregiver who provides 8 hours of
  care for each 24 hour day

148
Tech Waiver

• For Younger than 21 depend at least part of day
  on mechanical ventilator, OR prolonged IV
  nutritional supplements, drugs, or peritoneal
  dialysis, OR daily dependence on other
  device-based respiratory or nutritional support.
• For 21 and Older depend at least part of each
  day on mechanical ventilator, OR requires
  prolonged IV nutritional supplements, drugs, or
  ongoing peritoneal dialysis.

149
Tech Waiver

• Services offered under this waiver are
• Private Duty Nursing
• Environmental Modifications
• Respite Care
• Personal Care

150
Important Information

• The Facility and Home Based Services Unit phone
  number is 804-225-4222.
• The Waiver Services Unit phone number is
  804-786-1465.
• Our Fax number is 804-371-4986.
• Please feel free to visit our web site at
  www.cns.state.va.us/dmas

151
Thank You!!

• We look forward to working with you to make this
  a successful partnership!