16 Del. Admin. Code § 20000-20102
The first of two steps in the application process is to determine medical eligibility. This is usually determined by Pre-Admission Screening (PAS). Referrals to PAS may come from the family of the applicant as well as other sources.
There are four levels of nursing facility care for which Medicaid can make payment to qualified providers.
Skilled Nursing Facility Level of Care - Skilled nursing facility (SNF) is an institutional setting which provides skilled nursing or rehabilitation services for mental or physical conditions. Such a setting includes availability of around the clock professional nursing observations, assessment or intervention.
Super Skilled indicates a payment methodology to accommodate respirator and some other skilled level patients as recommended by the DSS Medical Operations Administrator.
Intermediate Nursing Facility Level of Care Intermediate care nursing facility (ICF) is an institutional setting in which nursing and allied health care and support services are provided on a daily basis. Such services are supervised by but not necessarily given by a licensed nurse.
Intermediate Care Facility for the Mentally Retarded (ICF/MR) An intermediate care facility for the mentally retarded (ICF/MR) is a residential setting which offers comprehensive habilitative and support services to persons with mental retardation or related conditions. To qualify for an ICF/MR level of care, individuals exhibit significant deficits in age-appropriate functioning in multiple domains. As a consequence, they require frequent assistance or supervision to competently or safely engage in activities of daily living (ADLs).
Intermediate Care Mental Disease Level of Care (ICF/MD) results from a primary psychiatric diagnosis and indicates a need for services in an institution licensed to care for psychiatric patients. Medicaid vendor payments can only be made for persons who are 65 years of age and older.
An intermediate care facility for mental disease (ICF/MD) is a residential setting which offers comprehensive clinical and support services to persons with significant behavioral health disorders. Such disorder must compromise functioning in multiple areas and require frequent or intensive medical or behavioral interventions (e.g., drug therapy; professional counseling; behavior management techniques).
There are two ways to determine the medical necessity of nursing facility care. These are:
The Medicaid Long Term Care Unit's Pre-Admission Screening team performs a level of care determination for individuals in hospitals or in the community who will be entering a privately funded or public skilled or intermediate care facility. This includes individuals currently residing out-of-state who are seeking nursing facility placement in Delaware. The determination is made in accordance with guidelines established by the Medicaid program. The initial determination for applicants requiring a super skilled level of care is made by PAS. The Medical Review Team then confirms the determination of the necessity of super skilled care.
The Medical Review Team determines the level of care for the following groups:
individuals seeking out of state inpatient rehabilitation hospital care,
superskilled Reimbursement level of care,
Children Community Alternative Disability Program.
A MAP-25 (Comprehensive Medical Report) is completed by the attending physician and is submitted to the State Office Medical Review Team along with any supporting documentation for approval.
15 DE Reg. 202 (08/01/11)
PAS POL 20102.3 PRE-ADMISSION SCREENING AND RESIDENT REVIEWS (PASRR) OVERVIEW
By Federal mandate, all individuals applying for placement in a Medicaid certified nursing facility, regardless of pay source, must have a Level I Pre-Admission Screening and Resident Review (PASRR) for Mental Illness (MI) or Mental Retardation (MR)/Related Condition (RC).
Based on results of a Level I PASRR Screening, the PAS RN may determine that further screening, a Level II PASRR, is warranted. A Level II PASRR evaluates clients with MI and MR/RC and determines if nursing home placement, either with or without specialized services, is appropriate. In addition to the PAS RN, an Independent Contracted Psychiatrist also makes placement recommendations. However, the final decision on appropriate placement for individuals with MI or MR/RC is made by the State Mental Health Authority for MI or the Division of Developmental Disabilities Services for MR/RC.
PAS POL 20102.3.1 PRE-ADMISSION SCREENING AND RESIDENT REVIEWS (PASRR)
This applies to all nursing home applicants or residents of a Medicaid certified nursing facility (NF) regardless of payment source or diagnoses.
DMMA will assure PASRR program operates in accordance with federal regulations.
A Level I screening is the process of identifying individuals who are suspected of having a mental illness or mental retardation or if categorical determinations are met.
The Nursing Facility is responsible for completing the Level I screening for non-Medicaid individuals.
The Division of Medicaid and Medical Assistance is responsible for completing the Level I screening for Medicaid and potential Medicaid individuals when notified.
Based on the Level I screening, the individual will meet one of three categories:
| · | No indication of mental illness/mental retardation/related condition - nursing home admission/continued stay is appropriate - No further evaluation is needed. |
| · | There are indicators of mental illness/mental retardation/related condition however individual meets any of the following Physician's Exemption Criteria: |
| · | Primary Diagnosis of Dementia or related disorder. |
| · | Convalescent Care not to exceed 30 days - PAS nurses will track this exemption and initiate Level II PASRR evaluation prior to expiration if continued NF stay is warranted. |
| · | Terminal Illness - a life expectancy of 6 months or less if the illness runs its normal course. |
| · | Medical dependency with a severe physical illness. |
No further evaluation is needed at this time.
| · | There are indicators of mental illness, mental retardation/related conditions - Needs complete PASRR Assessment (Level II). |
DMMA PAS nurse will gather data for Level II PASRR screening.
Data is reviewed with DMMA Nurse Supervisor for approval to continue with the Level II screening.
The notice must inform them that the individual is being referred for Level II Evaluation to DSAMH due to mental illness indicators or to DDDS due to mental retardation/related condition.
The IPC will assess individual and review documentation to verify whether or not there is a serious MI.
DDDS will assess individual and review documentation to verify whether or not diagnostic criteria of mental retardation or related conditions are met.
The Level II evaluation may be terminated at any time if the evaluator determines that no Mental Illness is present.
DDDS will assess individual and review documentation to verify whether or not diagnostic criteria of mental retardation or related conditions are met.
The Level II evaluation may be terminated at any time if the evaluator determines that no Mental Retardation [or related conditions] is present.
DSAMH will review IPC's recommendations and determine need for Specialized Services and/or NF services.
| · | Individual applicant; |
| · | Legal Representative; |
| · | Admitting or retaining NF; |
| · | Attending Physician; |
| · | Discharging hospital - if exemption is not applicable. |
Final PASRR determinations will be issued by DMMA.
16 Del. Admin. Code § 20000-20102