Bulletin. Required Activity: Admission to Medicaid-Certified Nursing Facilities and 90-day Redetermination TOPIC PURPOSE CONTACT SIGNED

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1 Bulletin NUMBER # DATE August 7, 2017 OF INTEREST TO Cunty Directrs Scial Services Supervisrs and Staff Tribal Health Directrs Lng Term Care Cnsultatin Cntacts Nursing Facility Prviders Hspital Discharge Planners Certified Health Care Hme and Clinic Staff Managed Care Organizatins Senir LinkAge Line Staff Area Agency n Aging Directrs ACTION/DUE DATE Please cmplete PAS and ther activity as required fr NF admissins. EXPIRATION DATE August 7, 2019 Required Activity: Admissin t Medicaid-Certified Nursing Facilities and 90-day Redeterminatin TOPIC State and federal law require Pre-Admissin Screening (PAS) befre admissin t Medical Assistance (MA)-certified nursing facilities (NF) regardless f payer surce. PAS plicy prhibits any payment fr NF services prvided prir t cmpletin f PAS. If MA is r will be paying fr services, a secnd redeterminatin f NF level f care is required. PURPOSE Cmmunicate PAS OBRA Level I plicy and practice fr all admissins regardless f payer surce, as well redeterminatin f level f care fr Medical Assistance payment fr lnger stays. CONTACT senir.linkage@state.mn.us fr PAS OBRA Level I plicy and prtcls DSD.RespnseCenter@state.mn.us fr under 65 plicy dhs.nflc@state.mn.us fr NF Level f Care Criteria SIGNED LOREN COLMAN Assistant Cmmissiner Cntinuing Care fr Older Adults Administratin TERMINOLOGY NOTICE The terminlgy used t describe peple we serve has changed ver time. The Minnesta Department f Human Services (DHS) supprts the use f "Peple First" language. Minnesta Department f Human Services PO Bx St. Paul, MN

2 Page 2 I. Backgrund Federal and state laws require that ALL individuals entering a Medical Assistance (MA)-certified nursing facility (NF), a certified barding care facility, r a hspital swing bed receive a Pre-Admissin Screening (PAS), regardless f the anticipated length f stay r the payer surce fr facility services. Per Minnesta Statutes, sectin , subdivisin 7 7c gverning the activities and services carried ut by the Minnesta Bard n Aging, Senir LinkAge Line (SLL) staff cnduct mst PAS activities, with sme exceptins. In additin, thse n MA r applying fr MA are required t meet the nursing facility (NF) level f care (LOC) criteria 90 days after admissin in rder fr MA t cntinue r begin t pay fr services. This requirement is described in Minnesta Statutes, sectin , subdivisin 11 gverning nursing facility resident classificatins and reimbursement. When PAS is mentined thrughut this bulletin it refers t LOC determinatin and screening individuals fr develpmental disabilities r mental illness. The screening activity that is part f PAS is referred t as OBRA Level I screening. This bulletin is related nly t PAS OBRA Level I plicies and practices. Resurces fr OBRA II activities, which are mre extensive evaluatins based n referrals resulting frm OBRA Level I screening, are lcated in sectin XIV. This bulletin utlines PAS plicies and requirements, including: Initiatin f the cmpletin f PAS r 90-day redeterminatin by using nline tls; Cmmunicatin related t PAS by Senir LinkAge Line with health care prfessinals, NF prviders, managed care rganizatins (MCOs) and lead agency care crdinatrs/case managers; and Infrmatin related t MMIS dcumentatin required t cmplete a PAS and ensure fee-fr-service nursing facility payment fr peple participating in Minnesta Health Care Prgrams (MHCP). There are als tw attachments included: Attachment A is a table shwing: Referrals that will be made by SLL staff when PAS has been cmpleted by SLL and respnsibilities f the lead agency wh receive the referral; and Additinal tasks that must be cmpleted by a lead agency when a PAS is NOT cmpleted by SLL. Attachment B includes infrmatin abut MMIS system edits related t PAS fr NF claims. II. Purpse f Pre-Admissin Screening (PAS) PAS requirements apply t all admissins t a MA-certified NF, a certified barding care facility, r a hspital swing bed 1, regardless f the payer surce fr facility services, length f stay r age f cnsumer. Fr purpses 1 A swing bed is ne that has been certified as bth an acute hspital and NF bed, and that, under special circumstances, may be used fr Medicare skilled nursing facility days. In additin, in seven hspitals designated as "Sle Cmmunity Prviders," MA nursing facility rm and bard days may be prvided as swing bed days. Requirements fr use f swing beds are utlined in the Minnesta Health Care Prgrams Prvider Manual. All ther Minnesta Department f Human Services PO Bx St. Paul, MN

3 Page 3 f PAS plicy and requirements, the term facility r NF refers t all three settings thrughut this bulletin. Unless an admissin meets ne f the exemptins utlined in Sectin VII, PAS must be cmpleted PRIOR t admissin. PAS is cmpleted t: Avid unnecessary facility admissins by identifying peple whse needs might be met in the cmmunity and cnnecting them t cmmunity-based services; Screen peple fr mental illness r develpmental disabilities based n the requirements in the Omnibus Budget Recnciliatin Act (OBRA) f 1987, als referred t as OBRA Level I screening. This screening is cmpleted t identify and refer individuals t ther prfessinals fr evaluatin f the need fr specialized mental health r develpmental disability services as required under federal law. These activities are referred t as OBRA Level II activities 2 ; Determine and dcument the need fr NF services in the Medicaid Management Infrmatin System (MMIS) fr purpses f MA payment fr NF services; Identify individuals wh can benefit frm assistance after NF admissin t supprt transitin back t the cmmunity. III. Senir LinkAge Line Respnsibility fr PAS OBRA Level I A. Pre-Admissin Screening Respnsibility Statewide respnsibility fr PAS, including OBRA Level I screening, was assigned t the Minnesta Bard n Aging in 2013, and is gverned by Minnesta Statutes, sectin , subdivisins 7 7c. A PAS request is submitted by a health care prfessinal seeking NF admissin thrugh a single nline site, and the request is frwarded electrnically t the Senir LinkAge Line fr prcessing. Senir LinkAge Line is respnsible t perfrm PAS fr all individuals except: Peple enrlled int ne f the fllwing prepaid Medical Assistance prgrams: Minnesta Senir Health Optins (MSHO) Minnesta Senir Care Plus (MSC+) Special Needs Basic Care (SNBC) Individuals n a hme and cmmunity-based services waiver, Alternative Care (AC) prgram r Essential Cmmunity Supprts (ECS); and Individuals under the age f 21. requirements fr the use f these beds must be met, regardless f payer surce, including claims prcessing prcedures and Minnesta Department f Health apprval fr stays as needed. 2 OBRA Level II activities and requirements are nt included in this bulletin. Please see Sectin XVI fr resurce infrmatin related t OBRA Level II. Minnesta Department f Human Services PO Bx St. Paul, MN

4 Page 4 In these instances, the Senir LinkAge Line will frward infrmatin t the apprpriate lead agency staff wh are then respnsible fr all PAS-related activity. Mre infrmatin is available in Sectin IV abut lead agency respnsibility fr PAS. B. Cmpleting a Pre-Admissin Screening Request Online Only a qualified health care prfessinal can determine if admissin t a nursing facility is apprpriate. A qualified health care prfessinal is the physician determining the need fr nursing facility placement and writing the admissin rders. This is limited t physicians within hspitals, clinics and hspice prviders. Hwever, staff assciated with the health care prfessinal, such as administrative staff r nurses within the hspital r clinic where the physician wrks may cmplete the nline referral fr a PAS after the health care prfessinal has made this determinatin. Nursing facility staff may als cmplete the nline referral fr a PAS if it has nt yet been requested. Registered husing with services (assisted living) and ther hme care r hme and cmmunity-based service prviders are nt cnsidered qualified health care prfessinals fr the purpses f initiating PAS. The request fr PAS must be made thrugh the nline referral site. Users are encuraged t bkmark this page fr easy access. Cmpleting a PAS nline ensures that all required infrmatin is entered, reducing any delays in cmpletin f PAS due t incmplete data. In additin, an initial, but nt final, nursing facility level f care and OBRA Level I result will be cmmunicated electrnically t the submitter after cmpletin. Once submitted, the submitter will receive an utput message clarifying if further assessment is needed. If the health care prfessinal des nt have enugh infrmatin t cmplete the PAS referral nline, he/she can cmplete the nline frm t the best f his/her ability and submit it. The Senir LinkAge Line will then determine whether a face-t-face assessment frm a cunty, tribe r managed care rganizatin (MCO) is needed. The health care prfessinal can als use infrmatin prvided by ther health care prviders, such as medical specialists and hme care prviders, if necessary, t cmplete the nline frm. If there is nt enugh infrmatin knwn t cmplete the nline frm, the health care prfessinal can make a referral t the cunty, r MCO if knwn, fr a face-t-face assessment t determine if the cnsumer meets nursing facility level f care. The referral shuld be made t the cunty where the hspital r clinic is lcated. Please ensure the Finish buttn has been selected and an utput frm cntaining a cnfirmatin number appears. If this step is nt cmpleted, the referral will nt be submitted t the Senir LinkAge Line. Nte that the cnfirmatin number is nt a required element f the PAS, but prvides dcumentatin that the PAS was submitted nline successfully, and serves as a reference fr the Senir LinkAge Line if questins arise. It is advised that the health care prfessinal print the referral and results fr their wn recrds, as well as prvide a cpy t the admitting facility with ther discharge paperwrk t prevent admissin delays. The Senir LinkAge Line will strive t cmplete r triage all PAS requests within ne business day with the exceptin f state-recgnized hlidays. The admitting nursing facility will be made aware that the PAS was cmpleted and whether it was prcessed by the Senir LinkAge Line r frwarded t a lead agency fr prcessing. Minnesta Department f Human Services PO Bx St. Paul, MN

5 Page 5 A step-by-step fr health care prfessinals t cmplete the nline referral is available nline. This step-by-step and all ther infrmatin will be updated as changes t the nline site are made. IV. Lead Agency Respnsibility fr PAS While Senir LinkAge Line is nt respnsible t perfrm PAS fr peple enrlled in certain prepaid medical assistance prgrams (managed care) r fr individuals wh are participating in a hme and cmmunity-based prgram at the time f admissin, mst requests fr admissins will begin with a submissin f the nline frm by a health care prfessinal. The Senir LinkAge Line will retrieve the referral infrmatin and frward the PAS request t the apprpriate lead agency via a secure bx fr cmpletin f PAS and related activities when necessary. A lead agency is a cunty, tribe r MCO with respnsibility fr prviding services under the Lng Term Care Cnsultatin prgram, including access t HCBS prgrams. Lead agencies are als respnsible t prvide nging case management t HCBS prgram participants. Infrmatin abut the lead agency respnsibility fr PAS fr peple enrlled in managed care r participating in HCBS prgrams is fund in this sectin. When a PAS referral is submitted nline fr peple wh must have a face-t-face assessment befre admissin, Senir LinkAge Line will frward the PAS request and infrmatin t the lead agency respnsible t perfrm the face-t-face assessment. Mre infrmatin abut face-t-face assessment fr purpses f PAS is fund in IV.C. Attachment A prvides detailed infrmatin abut the cmmunicatins prcesses and agency respnsibility fr PAS activities fr the varius ppulatins described abve. A. PAS fr Peple Enrlled in Prepaid Medical Assistance Prgrams ( Managed Care ) Once Senir LinkAge Line frwards the PAS request t the individual s managed care rganizatin (MCO) via a secure bx, the qualified prfessinal assigned by the MCO t cmplete PAS activity will then take all necessary actins. Prfessinals qualified t cmplete PAS, as defined in the cntract between the MCOs and the Minnesta Department f Human Services (DHS), r the MCO s qualified designee, must fllw the same PAS timelines, prcedures and MMIS dcumentatin requirements as utlined in this bulletin. Please see Sectin XIV fr resurce infrmatin abut the mdel cntracts fr each f the prepaid medical assistance prgrams listed abve. Fr peple wh are enrlled in the managed care prgrams listed in III.A, the individual s MCO is respnsible t: Perfrm determinatins f the need fr NF level f care; Cmplete OBRA Level I screening; Prvide dcumentatin f the PAS result t the admitting nursing facility; Frward infrmatin, if apprpriate, t the designated cunty fr OBRA Level II activity (See Attachment A); and Minnesta Department f Human Services PO Bx St. Paul, MN

6 Page 6 Enter PAS infrmatin int MMIS using the Lng Term Care Screening dcument. See Sectin IV.B. fr infrmatin abut admissin f hme and cmmunity-based services waiver, Alternative Care r Essential Cmmunity Supprt participants. Fr thse wh receive their health care services under MSHO r MSC+, the individual s MCO is als respnsible t prvide relcatin assistance t all f their enrlled members. Cntact infrmatin fr each MCO can be fund n the Minnesta Department f Human Services website r by nursing facility prviders when accessing the MN-ITS eligibility system. B. Hme and Cmmunity-Based Services and PAS: AC, Waiver and ECS Participants Peple wh are participating in the Alternative Care (AC), Elderly Waiver (EW), Cmmunity Alternative Care (CAC), Cmmunity Access fr Disability Inclusin (CADI) r the Brain Injury (BI)- NF waiver prgrams n the date f NF admissin, and wh cntinue t meet NF Level f Care (LOC) criteria, are nt required t receive PAS thrugh the nline referral system prir t admissin t a NF. These individuals have the right t chse between hme and cmmunity-based and institutinal services because nursing facility level f care has been established as part f their HCBS prgram eligibility determinatin. This exceptin des nt include individuals participating in the Develpmental Disability (DD) Waiver prgram (a prgram fr individuals with develpmental disability and an Intermediate Care Facility/Develpmental Disability (ICF/DD) level f care), all individuals under age 21, nr thse n Essential Cmmunity Supprts (ECS). See Sectin IV.C. fr mre infrmatin abut admissin f these individuals, wh may require a face-t-face assessment prir t admissin t a NF. When HCBS participants are admitted t the NF frm the cmmunity: When HCBS participants are admitting t the NF frm the cmmunity, the lead agency prviding case management fr the cnsumer must take the fllwing actins: OBRA Level I screening cmpleted as part f the face-t-face assessment must be frwarded t the facility by the lead agency. The DHS-3426 OBRA Level I frm includes verificatin that the persn cntinues t meet NF LOC at admissin and shuld be re-dated by the lead agency. Nursing facility prviders shuld always receive this dcumentatin. Lead agencies d nt cmplete a PAS referral nline fr NF admissins f waiver, ECS r AC clients. Lead agencies fllw the plicy related t exiting individuals frm a waiver, AC, r ECS prgram. Fr mre infrmatin abut Temprary Waiver Exits please refer t the Cmmunity Based Services Manual (CBSM). All required OBRA Level II activities must be cmpleted prir t admissin. When HCBS participants are admitted t the NF frm a hspital r clinic: Mst health care prfessinals submitting the nline PAS request will nt knw if a cnsumer is n an HCBS prgram, and will be submitting nline PAS requests fr all individuals. When an nline PAS referral is cmpleted fr an individual participating in ne f the HCBS prgrams listed abve, the frm will nt be prcessed by Senir LinkAge Line and instead: Minnesta Department f Human Services PO Bx St. Paul, MN

7 Page 7 Senir LinkAge Line will frward the PAS utput frm t the lead agency respnsible fr case management t cmmunicate infrmatin abut a requested admissin fr an HCBS participant. When a cnsumer is n a waiver (with the exceptin f DD), AC r ECS, Senir LinkAge Line staff will nt and cannt cmplete the PAS, nr enter it int MMIS, due t this participatin and ther actins that must be cmpleted by the lead agency. The lead agency must frward a cpy f the DHS-3426 OBRA Level I frm t the NF. If the lead agency has received a PAS utput frm because a health care prfessinal cmpleted an nline PAS referral, this frm can be sent t the NF with the DHS-3426 OBRA Level I frm, but is nt required. The Senir LinkAge Line will als frward a cpy f the PAS utput frm, alng with a letter that prvides infrmatin t the NF regarding the referral t a lead agency, and that indicates that the PAS is nt final until dcumentatin is received by the NF frm the lead agency. This letter will include the lead agency cntact infrmatin in the event the NF has questins r cncerns. Please see Attachment A fr mre infrmatin abut cmmunicatins cmpleted by Senir LinkAge Line t ther lead agencies and lead agency respnsibilities. C. Nursing Facility Admissins and Lead Agency Face-t-Face Assessments There are several circumstances in which a face-t-face assessment must be cmpleted t satisfy PAS requirements. Health care prfessinals seeking admissin will still use the nline frm t initiate PAS, and SLL will frward infrmatin t the apprpriate agency fr individuals listed belw t cmplete needed assessments and ther dcumentatin activity. The health care prfessinal wh initiated the PAS request will receive an utput message that NF LOC culd nt be determined and that the referral will be made. Fr individuals nt enrlled in MSHO, MSC+, SNBC r an HCBS prgram, SLL will make a referral t the cunty where the hspital r clinic is lcated t cmplete a face-t-face assessment t gather additinal infrmatin needed t determine NF LOC when LOC cannt be determined using the nline prcess. This assessment must be cmpleted within 20 days f referral and must be cmpleted prir t admissin. Fr individuals in MSHO r MSC+, the MCO must cmplete a face-t-face assessment fr enrllees when NF LOC cannt be determined using the infrmatin cntained in the nline frm. Fr individuals in SNBC, the MCO will refer t the cunty f financial respnsibility fr the face-t-face assessment. Fr individuals participating in ECS, there must be a determinatin f NF LOC thrugh a face-t-face assessment/reassessment, since ECS participants d NOT meet NF LOC criteria. This is true fr individuals in managed care wh entered the ECS prgram under the transitin t the revised NF LOC criteria in As with ther HCBS prgram participants, the lead agency prviding case management is respnsible t cmplete the face-t-face assessment and ther activities listed belw, and will receive the referral infrmatin frm the SLL when a PAS request has been submitted nline. Minnesta Department f Human Services PO Bx St. Paul, MN

8 Page 8 In all cases, this assessment must be cmpleted within 20 days f referral and must be cmpleted prir t admissin. When PAS has been cmpleted via a face-t-face assessment, and the persn chses facility-based services, the agency cmpleting the assessment must: Cmplete OBRA Level I screening; Prvide dcumentatin f the PAS result and OBRA Level I dcumentatin t the admitting nursing facility; Frward, if apprpriate, infrmatin t the designated cunty fr OBRA Level II activity; and Enter PAS infrmatin int MMIS using the Lng Term Care Screening dcument. All individuals under age 21 and individuals with develpmental disability f any age must have a facet-face assessment cmpleted, and DHS apprval, befre admissin t an NF. See Sectin V fr additinal infrmatin fr these admissin requests. V. Admissin f Peple under 21 and/r with a Develpmental Disability r Related Cnditin Regardless f the exemptins utlined in Sectin VII, r Senir LinkAge Line /lead agency respnsibility utlined elsewhere in this bulletin, DHS must apprve all admissins f peple under age 21 and peple with develpmental disabilities r related cnditin f any age. Individuals Under 21: Fr all individuals under the age f 21, a face-t-face assessment must ccur befre admissin, regardless f prjected length f stay r admissin surce. This requirement is intended t prevent admissin f this ppulatin whenever pssible by develping cmmunity-based supprt and care plans that will meet the individual s needs in a less restrictive envirnment. At the face-t-face assessment, all cmmunity alternatives must be explred and presented t the persn, his/her family and/r the persn s legal representative. If a NF admissin cannt be prevented, the admissin must be apprved by DHS by calling r tll-free at Individuals with a Develpmental Disability r Related Cnditin: Admissin f a persn f any age with a develpmental disability r related cnditin t a NF must als be apprved by DHS and must include an apprved length f stay. This includes individuals in managed care as well as peple receiving HCBS services under the DD waiver prgram. The lead agency btains this apprval thrugh the fllwing tasks: Cmplete DD Screening in MMIS (Actin Type 01); Cmplete an OBRA Level II Evaluative Reprt based n the utcme f the DD Screening; Recrd the final dispsitin under Sectins I-III f the Evaluative Reprt in the case manager cmment sectin f the DD Screening; Submit the cmpleted DD Screening (Actin Type 01) t DHS via MMIS t verride lcatin 570 fr review and apprval immediately after the Evaluative Reprt and the DD Screening are cmpleted; Minnesta Department f Human Services PO Bx St. Paul, MN

9 Page 9 Once the DD Screening is in Apprved status in MMIS, recrd the Dcument Cntrl Number and the date n which the DD Screening was authrized by DHS n the bttm f the OBRA Level II Evaluative Reprt; Cmplete OBRA screening infrmatin can be fund in the Cmmunity-Based Services Manual (CBSM). Additinally, infrmatin abut DD Screening and DD Screening Dcument cmpletin can be fund n the Minnesta Department f Human Services website; Individuals wh receive services under ne f the DD waivers must have their waiver service agreements clsed as f, r prir t, the date f NF admissin, in rder t be exited frm the waiver; Prviders are respnsible fr a new DD screening if the length f stay exceeds the riginal apprved length f stay; NOTE: In additin t the steps utlined abve, fr individuals n a DD waiver and nt n a managed care plan, Senir LinkAge Line will enter the PAS OBRA Level I int MMIS. Fr individuals n a managed care plan and the DD waiver, the managed care plan is respnsible fr entering the PAS OBRA Level I int MMIS prir t cmpletin f OBRA Level II activity and DHS apprval. VI. Additinal Referrals and Cmmunicatins fr Peple Under 65 As described in Minnesta Statute, sectin 256B.0911, subdivisin 4d., all individuals under age 65 admitted t a facility must be visited after admissin t prvide infrmatin abut cmmunity based service ptins and resurces, based n an assessment cmpleted during the visit. This visit is required regardless f participatin in Minnesta Health Care Prgrams. The timeline fr this fllw up visit was amended during the 2017 Legislative sessin frm within 40 days after admissin t a date t be determined by the Cmmissiner. Effective fr admissins ccurring n r after July 1, 2017, the visit must ccur within 80 days f admissin. The timeline in which the visit was t ccur was extended t reflect: mre recent examinatin f NF length f stay experience fr peple under age 65; additinal relcatin activities that have been adpted since the riginal visit requirement was implemented, and delivery f this service t individuals wh, withut interventin r assistance, appear t be mre likely t becme lng term NF residents. All ther requirements related t the purpse and activities t be undertaken at the visit, including assessment, and the cunty respnsibility t cmplete the visit, remain the same under Minnesta Statutes, sectin 256B.0911, subdivisin 4d. When Senir LinkAge Line has cnducted a PAS, Senir LinkAge Line will prvide ntificatin t lead agency staff that an individual under age 65 has been admitted t a nursing facility. This cmmunicatin will supprt lead agencies in the timely cmpletin f fllw up face-t-face assessments fr peple under age 65. Minnesta Department f Human Services PO Bx St. Paul, MN

10 Page 10 Hwever, in thse cases where Senir LinkAge Line is nt cmpleting the PAS and has made a referral t a lead agency, such as fr HCBS prgram participants, the Senir LinkAge Line will cntinue t alert the apprpriate lead agency that the cnsumer is under the age f 65 and will need a fllw-up face t face assessment by the 80 th day f admissin. Please g t the Cmmunity-Based Services Manual fr additinal infrmatin abut MnCHOICES assessment requirements fr peple under age 65. Please see Attachment A fr mre cmplete infrmatin abut cmmunicatins cmpleted by Senir LinkAge Line t ther lead agencies, lead agency respnsibilities, and next steps. VII. Exemptin frm OBRA Level I and NF LOC Requirements A. Individuals Wh D Nt Require an Online Referral Prir t Admissin Sme individuals can be admitted t a nursing facility withut the cmpletin f an nline PAS referral. They include: Individuals wh have received a face-t-face assessment cmpleted by a lead agency, wh are nt n a waiver prgram r AC, and chse t enter an NF fr services can d s withut an nline referral, as lng as they enter a facility within 60 days f the date f the assessment, and when the assessment utcme indicates the persn meets NF LOC. Individuals wh are participants in the waiver prgrams (with the executin f the DD waiver) r AC n the date f admissin can chse t receive NF services withut an nline referral r additinal face-t-face assessment, as lng as they cntinue t meet NF LOC criteria at admissin. See Sectin IV fr mre infrmatin abut admissins f individuals participating in HCBS prgrams. Nte: this exceptin des nt apply t peple wh are participants in the Essential Cmmunity Supprts prgram, since this prgram supprts individuals wh DO NOT meet NF LOC criteria. See Sectin IV fr PAS requirements fr this ppulatin. As previusly nted, mst health care prfessinals submitting the nline PAS request will nt knw if a cnsumer has had a previus assessment r is n an HCBS prgram, and will be submitting nline PAS requests fr all individuals. In all cases f face-t-face assessment used fr NF admissin, the lead agency will enter a Lng Term Care Screening dcument in MMIS that verifies NF level f care is met and OBRA Level I Screening has been cmpleted. OBRA Level I screening cmpleted as part f the face-t-face assessment must be frwarded t the admitting facility by the lead agency. Nursing facility prviders shuld always receive this dcumentatin. Please nte the updated OBRA Level I Screening Frm (DHS Frm 3426) allws the lead agency t dcument NF level f care and the date the frm was cmpleted r updated. Minnesta Department f Human Services PO Bx St. Paul, MN

11 Page 11 Lead agencies shuld nt cmplete a PAS referral nline fr NF admissins that result frm a face-t-face assessment r admissin frm an HCBS prgram. Any required OBRA Level II activities must als be cmpleted prir t admissin. B. Interfacility Transfers There is ne type f admissin that is exempt frm bth NF LOC determinatin and OBRA Level I screening, based n qualifying inter-facility transfers. This exemptin applies regardless f payer surce fr facility-based services. There are tw types f qualifying inter-facility transfers: NF-t-NF transfer: A persn des nt need a new PAS if they are transferring frm ne MA-certified nursing facility, hspital swing bed r certified barding care facility in Minnesta t anther MAcertified nursing facility, hspital swing bed r certified barding care facility in Minnesta. NF-t-acute hspital-t-nf transfer: A new PAS is nt required when a persn has transferred frm a MA-certified NF r MA-certified barding care in Minnesta t an acute (nn-psychiatric) hspital and then back t the same r anther MA-certified NF r certified barding care in Minnesta, as lng as the persn des nt return t the cmmunity between these transfers. These are the ONLY types f transfers that are exempt frm PAS requirements because it is assumed that apprpriate PAS ccurred at the first NF admissin. NFs are respnsible t ensure that dcumentatin f previus OBRA Level I screening results accmpany ther recrds frwarded when residents transfer t anther facility, including thse transfers that ccur with an intervening acute hspital admissin. Shuld a cpy f a previus OBRA Level I screening nt be available r the previus screening results are Cannt Be Determined fr level f care, the admitting nursing facility may call the Senir LinkAge Line at r chat nline t request a cpy, r cmplete a new nline PAS referral t ensure cmpletin and dcumentatin f the PAS, as well as apprpriate screening fr NF LOC. Please als nte that a PAS may be cnsidered valid fr up t 60 days prir t admissin. If the cnsumer has been discharged t the cmmunity, but the PAS was cmpleted within 60 days f the secnd admissin, a new PAS wuld nt be needed. VIII. Facilities Prviding Hme and Cmmunity-Based Respite Services Neither NF level f care determinatin nr OBRA Level I screening is required when an individual, enrlled in a waiver prgram (with the exceptin f a DD waiver) r AC is receiving ut-f-hme respite in a nursing facility IF: The facility has enrlled as a waiver r AC respite prvider under MHCP Prvider Enrllment requirements, and The facility has been authrized by the case manager r service r care crdinatr t prvide respite services fr the individual as indicated n the service agreement prduced by MMIS r by the MCO, and The facility is nt prviding r billing fr NF services fr the individual. Minnesta Department f Human Services PO Bx St. Paul, MN

12 Page 12 Fr mre infrmatin abut ut-f-hme respite services under HCBS prgrams, please visit the Minnesta Department f Human Services website. IX. Additinal Plicy Infrmatin Please nte infrmatin in this sectin is nt new plicy r prcess. MA prgram participants must apply specifically fr Lng-Term Care services using the MHCP Request fr Payment f Lng-Term Care Services Frm (DHS-3543), if they have nt already dne s. See HCPM MHCP LTC Requests and Applicatins. MA HCBS waiver prgram participants d nt need t cmplete this applicatin as this was already cmpleted. Financial wrkers will nt determine MA eligibility fr Lng Term Care services withut dcumentatin that an individual meets an institutinal level f care. Fr purpses f NF LOC, the financial wrker relies n fllwing current prcess: A financial wrker relies n DHS frwarded frm the NF t verify cmpletin f Pre-Admissin Screening. MMIS claims edits lk fr the actual screening dcument that captures PAS and LOC infrmatin as part f claims payment verificatin editing. A financial wrker must receive DHS-5181 frm a MnCHOICES assessr r health plan care crdinatr t verify NF LOC fr face-t-face assessments r HCBS participatin. Financial wrkers als must receive DHS-5181 when a face-t-face assessment has been cmpleted t determine NF LOC, as part f PAS when NF LOC has nt been able t be established using the nline PAS nline referral site. Financial wrkers will cntinue t cmmunicate financial eligibility determinatins t facility residents using DHS-4915, and t NF prviders using DHS Only lead agency assessrs can prvide ntificatin that an individual des NOT meet NF LOC. When NF LOC cannt be determined using the nline PAS prcess, Senir LinkAge Line will make a referral t the cunty where the persn is lcated at the time f the request t schedule and cmplete a face-t-face assessment. MCOs must als cmplete a face-t-face assessment f enrlled members when NF LOC cannt be determined using the infrmatin cllected in the nline PAS referral frm and frwarded by Senir LinkAge Line t the MCO. Nursing facilities are required t prvide each persn admitted with infrmatin abut assistance available t return t the cmmunity, as required under Minnesta Statutes, sectin 256B Facilities prvide this infrmatin using DHS Prmting and Supprting Independent Cmmunity Living. When a persn is seeking admissin t a Minnesta MA-certified swing bed, nursing facility r barding care facility and resides in anther state r is transferring frm an ut-f-state facility: The Senir LinkAge Line must perfrm PAS fr all persns seeking admissin t a certified nursing facility, barding care facility r MA-certified swing bed in Minnesta, regardless f the persn s state f residence. In this case, the health care prfessinal seeking admissin (e.g. Nrth Dakta hspital discharge planner) r the ut-f-state nursing facility must cmplete the nline PAS referral prir t admissin. Nte: Transfers frm an ut-f- Minnesta Department f Human Services PO Bx St. Paul, MN

13 Page 13 state nursing facility t a Minnesta nursing facility are nt cnsidered exempt frm PAS. Only transfers between Minnesta facilities can be cnsidered exempt. When a Minnesta resident is seeking admissin t a NF in anther state: The statute gverning PAS and MnCHOICES des nt require the Senir LinkAge Line t perfrm a PAS r the lead agency t cmplete a face-t-face assessment fr a Minnesta resident that is being admitted t an ut-f-state NF. In this case, the Minnesta hspital, r ther health care prfessinal seeking admissin shuld fllw the PAS requirements f the state where the admitting facility is lcated. Hwever, if Minnesta MA is ging t be the payer fr the ut-f-state NF care, the ut-f-state facility must cmplete the nline PAS request fr entry int MMIS t allw fr payment. When a NF admissin ccurs withut PAS: Minnesta Statutes, sectin 256B.0911 prhibits MA and private pay payments fr NF services prvided prir t the cmpletin f required PAS. If a persn is nt exempt frm PAS, the NF will nt be paid until the nline screening r, if needed, a face-t-face assessment has been perfrmed and entered int MMIS. Neither the Senir LinkAge Line nr lead agency staff can backdate cmpletin f PAS in MMIS. Lead agencies shuld use the date the PAS was entered int MMIS as the date f referral fr the MnCHOICES/LTCC face-t-face assessment. Pre-Admissin Screening is valid fr 60 calendar days: If a persn received PAS either nline r thrugh a face-t-face MnCHOICES/LTCC assessment, that PAS is valid fr 60 calendar days. If the persn is under 65, the in-persn assessment is due within 80 calendar days after the date f admissin. All ther screening t determine NF LOC r fr OBRA Level II purpses must still be cmpleted prir t admissin. Nursing facilities may cntact Senir LinkAge Line t receive a cpy f the PAS. If the cnsumer is n a hme and cmmunitybased waiver, ECS r AC, the nursing facility shuld cntact the lead agency t btain a cpy f the OBRA Level I frm, but may cntact the Senir LinkAge Line if assistance btaining a cpy is needed. Emergency admissin t a certified NF, certified barding care, r swing bed: An emergency admissin is defined in Minnesta Statutes, sectin , subdivisin 7b gverning the Minnesta Bard n Aging. Emergency admissin frm the cmmunity t a certified nursing facility prir t screening is permitted during Senir LinkAge Line nnwrking hurs when all f the fllwing criteria are met: A physician has determined that delaying admissin until PAS is cmpleted wuld adversely affect the persn s health and safety; There is a recent event and the persn is nt able t live safely in the cmmunity, such as sustaining an injury, sudden nset f acute illness, r a caregiver is unable t cntinue t prvide care; The attending physician must authrize the emergency placement and dcument the reasn that emergency placement is recmmended; The Senir LinkAge Line must be cntacted n the first wrking day fllwing the emergency admissin. Hwever, PAS referrals can be made nline 24 hurs a day, including hlidays. Senir LinkAge Line will retrieve the frm n the next business day; and The admissin must ccur utside f Senir LinkAge Line business hurs (8:00am 4:30pm). The cnsumer was admitting t the nursing facility frm the cmmunity. This criteria als applies t a persn wh has had a hspital admissin fr bservatin (e.g., stabilizatin f medicatins), r fr Minnesta Department f Human Services PO Bx St. Paul, MN

14 Page 14 care in an emergency rm withut hspital admissin. Senir LinkAge Line staff will use the admissin date fr the Activity Type (screening) Date fr qualifying emergency admissins when the criteria abve are met. If these criteria are nt met, the date f actual screening is entered. After hurs admissins frm an in-patient hspital stay are nt cnsidered emergency admissins. The date f the Pre-Admissin Screening will be the date the PAS was received even if this is nt the same date f admissin. X. Dcumentatin f Pre-Admissin Screening OBRA Level I and NF LOC Activity in MMIS Senir LinkAge Line staff and MCO staff must dcument PAS activities using the MMIS LTC SDOC subsystem. Data t be entered int MMIS is captured in DHS 3427 r in the nline PAS referral utput frm. Fr sme individuals, a DD Screening Dcument (DHS-3067) is als cmpleted and entered int MMIS. Senir LinkAge Line cannt and is nt respnsible t enter infrmatin int MMIS fr individuals in managed care prgrams listed in Sectin III, nr fr individuals participating in the hme and cmmunity-based prgrams referenced in this bulletin. The lead agency (MCO, tribe r cunty) is respnsible t ensure apprpriate dcumentatin is entered int MMIS. The nly exceptin is thse n a DD waiver wh are nt als n a managed care plan. In these cases, Senir LinkAge Line will enter the Pre-Admissin Screening int MMIS prir t a referral t the cunty r tribe t cmplete apprpriate waiver and OBRA Level II activity. All PAS staff, whether Senir LinkAge Line, MCO r cunty r tribe, are respnsible t prvide dcumentatin t the facility that OBRA Level I was cmpleted, using DHS-3426 OBRA Level I Screening r a cpy f the nline PAS referral utput frm after review by Senir LinkAge Line. All PAS staff must als ensure that dcumentatin f level f care and OBRA Level I screening are entered int the MMIS LTC SDOC subsystem as described in DHS-4625, Instructins fr Cmpleting and Entering the LTCC Screening Dcuments and Service Agreements int MMIS. See Sectin XIV fr the web link t this manual, and the cmpanin manual fr MCOs, DHS-4669 and DHS-5020A. Please nte: Senir LinkAge Line will nt cmplete MMIS tasks fr HCBS r MCO participants (SNBC, MSHO and MSC+) admitted t facilities, with the exceptin f entering the PAS int MMIS fr DD waiver participants. When a face-t-face assessment has been cmpleted fr purpses f satisfying PAS requirements fr NF admissin, the lead agency must als cmplete MMIS dcumentatin capturing the assessment infrmatin and assessment utcmes as is cmpleted fllwing all face-t-face assessments. MA fee-fr-service payments will be made fr NF services nly when MMIS editing indicate that PAS requirements have been met. MMIS will cmpare claims fr NF services t Lng Term Care (LTC) and Develpmental Disabilities (DD) screening dcuments t verify PAS cmpletin. Failure t enter PAS infrmatin int MMIS timely can result in delays r denials f payments fr NF services. The infrmatin prvided belw pertains nly t edits related t PAS. Fr admissins ccurring n r after January 1, 2005, MMIS claims editing verifies that: PAS ccurred in a timely manner; The need fr NF level f care (NF LOC) is determined; Minnesta Department f Human Services PO Bx St. Paul, MN

15 Page 15 An OBRA Level I screening fr mental illness r a develpmental disability was cmpleted; DHS apprval is cmplete fr peple under age 21 and fr peple with develpmental disabilities and dates f services n claims match DHS-apprved length f stay fr these individuals; The PAS activity date (the Activity Date in MMIS) is related t the date f NF admissin; Infrmatin n the mst recent LTC Screening Dcument indicates NF level f care; and OBRA Level I screening was perfrmed, as indicated by data n the screening dcument. The date MMIS uses fr PAS editing: The facility must always use the persn s actual admissin date n every claim, as well as the dates f service billed n each individual claim, regardless f the payer surce fr any given perid. The financial wrker als uses the actual admissin date in the Recipient File (nt the date the persn became MA eligible r any ther date) t establish NF living arrangement. MMIS will lk at the admissin date n the claim and in the recipient file infrmatin in MMIS t edit fr all PAS requirements, including the valid screening date and the face-t-face visit timelines fr peple under age 65 admitted t facilities. XI. Preparatin f Claims Facilities can avid unnecessary denials f payment fr NF services by prperly preparing claims. Use the crrect admissin date n the claim. MMIS will apply PAS editing nly t admissins that ccurred n r after January 1, In additin, PAS editing will cmpare the date PAS was cmpleted t the actual date f admissin, nt the date the persn became eligible fr MA. Use the crrect admissin surce cde n the claim. This is imprtant fr inter-facility transfers. Transfers: Transfers frm ne Minnesta MA-certified facility t anther, r frm a Minnesta MAcertified facility t an acute hspital and back t a Minnesta MA-certified facility are exempt frm PAS requirements. A persn wh has been living in an assisted living setting and being admitted t a nursing facility IS NOT an inter-facility transfer. Husing with services settings are nt cnsidered facilities. Cmplete and frward DHS In additin, facilities shuld make sure that they have frwarded DHS t the persn s cunty financial wrker if MA is r will be the payer fr facility services. MCOs may als require additinal dcumentatin t be frwarded befre NF services will be paid. Bill the apprpriate payer. Nursing facilities can use the MN-ITS Eligibility system and the Nursing Hme Prepaid Health Plan Reprt by LTC prvider t identify admissins that are cvered under MCO benefits, and the MCO respnsible fr the benefit. On the MN-ITS Eligibility system, infrmatin indicating cases where the health plan has respnsibility fr nursing facility services immediately fllws the prepaid health plan infrmatin. The mnthly Nursing Hme Prepaid Health Plan Reprt by LTC prvider will include the fllwing infrmatin: Enrllee name Medicaid ID number (PMI) MCO name Minnesta Department f Human Services PO Bx St. Paul, MN

16 Page 16 Minnesta Health Care Prgram Prduct ID (M02 = MSHO, MA30 r MA35 = MSC+ and MA19 r MA37 fr SNBC) NF Liability Begin Date NF Liability End Date If the NF Liability Begin and End dates are blank, this indicates that the MCO des nt have respnsibility fr nursing facility services. If the end date cntains all 9s, this indicates that the health plan still had respnsibility fr nursing facility services at the time the reprt was generated (apprx. the 10th f each mnth). If there is a value ther than 9s in the NF Liability End Date, this indicates the last day the MCO had respnsibility fr NF services. Please nte, per the Minnesta Health Care Prgrams Prvider Agreement fr Nursing Hme Facilities, facilities wh sign this agreement agree t cmply with statement C which states, T cmply with all federal and state statutes and rules relating t the delivery f services t individuals and t the submissin f claims fr such services. XII. Nursing Facility Level f Care 90-Day Redeterminatin A. Qualifying 90-day Stay In rder t cntinue MA payment fr nursing facility services fr individuals admitted n r after Octber 1, 2014, NF LOC must be re-established 90-days after NF admissin, per Minnesta Statutes, sectin , subdivisin 11. Reassessment f an individual admitted t a NF after 90 days will als assist in identifying individuals wh may benefit frm relcatin assistance, and redirect individuals with lwer needs t ther types f supprt. Once a qualifying 90-day stay is established thrugh ne f the methds described in this sectin, n further demnstratin f level f care criteria is required fr the remainder f a cntinuus nursing facility stay. Level f care (LOC) will be established t meet the qualifying 90-day stay criteria fr individuals admitted n r after Octber 1, 2014, in ne f three ways: MDS Assessment and the Qualifying 90-Day Stay: The primary methd t establish LOC will be the use f the MDS quarterly assessment and resulting Resurce Utilizatin Grups (RUGs) classificatin. The determinatin f NF LOC using the MDS assessment is pssible because much f the infrmatin abut care needs that is used t establish LOC is als cntained in the MDS assessment tl used by nursing facilities. The MDS quarterly assessment establishes LOC fr all resulting RUGS classificatins except PA1 and PA2. Many individuals with PA1 and PA2 RUGS classificatins d meet NF LOC criteria. The PA1 and PA2 classificatins simply d nt prvide enugh infrmatin abut care needs t determine NF LOC withut further assessment. Qualifying 90-Day Stay Established by the Facility: If the relevant MDS assessment results in a RUGS classificatin f PA1 r PA2, the nursing facility will submit infrmatin thrugh the nline referral tl t establish that an individual meets LOC criteria. Minnesta Department f Human Services PO Bx St. Paul, MN

17 Page 17 The facility shuld attempt t establish the qualifying 90-day stay within three business days f receipt f the PA1 r PA2 classificatin t ensure timely referral fr a face-t-face MnCHOICES/LTCC assessment, if needed. Facilities will use the infrmatin cntained in the relevant MDS assessment t establish LOC using the nline tl, as well as additinal infrmatin cntained in the nline tl that is nt part f the MDS assessment. The utput frm frm the nline referral will prvide a result determining if a resident meets NF LOC r if it cannt be determined and further assessment is needed. The NF shuld print a cpy f this utput frm fr the resident s recrd. Qualifying 90-Day Stay: Face-t-Face MnCHOICES/LTCC Assessment: When the infrmatin prvided by the facility in cmpleting the nline PAS referral cannt determine LOC fr an individual with a PA1 r PA2 classificatin, a referral fr an in-persn MnCHOICES/LTCC assessment must be made. This referral fr a face-t-face assessment will be made by SLL after the facility has attempted t establish NF LOC via the nline tl. It is very imprtant t nte that a face-t-face assessment must be used t make a final determinatin that an individual des nt meet any criteria fr NF LOC. It cannt be cncluded by anyne ther than a lead agency assessr that an individual des nt meet any NF LOC criteria. B. When the Qualifying 90-day Stay Must be Established A qualifying 90-day stay is defined in tw different ways fr purpses f MA payment fr NF services: MA Participants: Fr an individual admitted n r after Octber 1, 2014, wh is participating in MA, a qualifying 90-day stay means the individual meets level f care criteria n bth the PAS at admissin AND at least 90 days after admissin t cntinue MA payment fr facility-based services. The primary methd that will be used t establish LOC t satisfy the qualifying 90-day stay requirement fr MA payment will be the first Minimum Data Set (MDS) quarterly assessment cmpleted by the NF apprximately 90 days after admissin. Individuals wh spend dwn t MA: The qualifying 90-day stay fr an individual wh was admitted t a facility n r after Octber 1, 2014, and wh subsequently spends dwn t MA means the individual must meet LOC based n the mst recent MDS quarterly assessment cmpleted prir t their effective date f MA eligibility. Examples: The examples here clarify the timelines related t admissin dates and the need t establish NF LOC t meet the qualifying 90-day stay criteria. It is assumed in all examples that individuals received preadmissin screening as required, and that LOC was established at PAS. Mr. Jnes was admitted n August 15, 2014, as a private paying resident. He cntinues his stay in the nursing hme and becmes Medicaid eligible n January 15, Because he was admitted prir t Octber 1, 2014, and has had a cntinuus stay, there is n need t re-establish LOC. Mrs. Green was admitted n August 15, 2014, with MA eligibility fr NF services based n PAS at admissin. She remains in the facility thrugh April Because she was admitted prir t Octber 1, 2014, and has remained in the facility, there is n need t re-establish LOC. Minnesta Department f Human Services PO Bx St. Paul, MN

18 Page 18 Ms. Smith was admitted n December 8, 2015, with MA eligibility fr NF services. Because she was admitted after Octber 1, 2014, and participating in MA, LOC had t have been reestablished based n her first MDS quarterly assessment ccurring in January, 2015 r, if needed, thrugh the nline tl r a face-tface assessment. Mr. Gray was admitted January 10, 2016, as a private pay individual. He became financially eligible fr MA in Nvember His LOC will be re-established using his last MDS quarterly assessment cmpleted prir t Nvember 2017 (typically ccurring in r arund Octber 2017 in this example) r, if needed, thrugh the nline tl r a face-t-face assessment. C. Inter-facility transfers and the qualifying 90-day stay An inter-facility transfer is the transfer f a resident between ne MA-certified nursing facility in Minnesta t anther MA-certified nursing facility in Minnesta. An inter-facility transfer may als include a transfer between ne MA-certified nursing facility in Minnesta t an acute care hspital and then t anther (r the same) MAcertified nursing facility in Minnesta. When a persn transfers between facilities as described in the paragraph abve, pre admissin screening is nt required t be cmpleted again. Hwever, if the persn transfers befre a qualifying 90-day stay has been established, the facility admitting the transferring individual will be required t establish the qualifying 90-day stay fr purpses f cntinuing MA payment fr NF services. Fr a MA-eligible individual admitted t a nursing facility n r after Octber 1, 2014, and wh subsequently transfers t a different facility prir t the cmpletin f their first quarterly MDS assessment at the first facility, the qualifying 90-day stay will be determined upn their first quarterly MDS assessment cmpleted at the new facility, r, if needed, thrugh the nline tl r a face-t-face assessment. Fr an individual wh transfers and subsequently spends dwn t MA, the qualifying 90-day stay will be based n the last quarterly assessment cmpleted by either facility, based n the assessment cmpleted mst recently befre the persn s effective date f MA eligibility, r, if needed, thrugh the nline tl r a face-t-face assessment. Examples: The examples here clarify the timelines related t inter-facility transfers and the qualifying 90-day stay. It is assumed in all examples that individuals received pre admissin screening as required, and that LOC was established at PAS. A MA-eligible persn enters NF-An n Octber 15, The individual is transferred 30 days later t NF-B. NF-B wuld need t establish the qualifying 90-day stay using the resident s first quarterly assessment cmpleted by NF-B. A private pay individual enters NF-A n January 6, The individual is transferred 45 days later t NF-B. The individual spends dwn and applies fr MA in July NF-B wuld need t establish the qualifying 90- day stay using the resident s last quarterly assessment cmpleted by NF-B prir t the persn s effective date f MA eligibility. An individual is admitted August 20, 2014, t NF-A and subsequently transfers t NF-B in January In January 2016, the individuals applies fr MA. There is n need t establish a qualifying 90-day stay by either Minnesta Department f Human Services PO Bx St. Paul, MN