D.C. Mun. Regs. tit. 29, r. 29-989
The purpose of this section is to establish the Department of Health Care Finance (DHCF) standards governing the District Medicaid assessment process for Long Term Care Services and Supports (LTCSS) and to establish numerical scores pertaining to the level of care required to establish eligibility for a range of LTCSS.
LTCSS are designed to assist persons with a range of services and supports including assistance with basic tasks of everyday life over an extended period of time. These include, but are not limited to, the Home and Community- Based Services Waiver for the Elderly and Persons with Physical Disabilities (EPD Waiver), Personal Care Aide (PCA) services offered under the Medicaid State Plan, nursing facility services, Adult Day Health Program (ADHP) services under the 1915(i) Home and Community-Based State Plan Option, and other services not intended to serve individuals with intellectual and developmental disabilities.
A Registered Nurse (RN) or Licensed Independent Clinical Social Worker (LICSW) employed by DHCF or its designated agent shall conduct an initial face-to-face assessment following the receipt of a request for an assessment for LTCSS made by any individual identified in Subsection 989.5.
Individuals identified in Subsection 989.5 may request an assessment for LTCSS by submitting a Prescription Order Form (POF). The POF is available on the DHCF website at http://dhcf.dc.gov.
The request for an assessment shall include any supporting documentation established by the respective long-term care program's regulations. An initial request for an assessment, or a subsequent request for reassessment for recertification or based upon a change in the individual's health status or acuity, may be made by the individual seeking services,his/her authorized representative, Elderly and Persons with Physical Disabilities HCBS Waiver (EPD Waiver) case manager, family member, or health care or social services professional.
With the exception of hospital discharge timelines, which are referenced under Subsection 989.15, the RN or LICSW employed by DHCF or its designated agent shall be responsible for conducting the face-to-face assessment of each applicant or beneficiaryusing a standardized needs-based assessment tool within five (5) calendar days of the receipt of a request for an assessment, unless:
The assessment shall:
The standardized needs-based assessment tool and corresponding user's manual are available for review in-person at the DHCF offices. To access a paper copy of the assessment tool for review, beneficiaries should contact their case managers and potential applicants should contact DHCF's Long-Term Care Administration (LTCA) via the LTCA Hotline at 202-442-9533.A summary of the assessment tool and instructions on how to access a paper copy of the complete assessment tool and corresponding user's manual are available on DHCF's website at www.dhcf.dc.go .
The face-to-face assessment using the standardized needs-based assessment tool for LTCSS shall result in a total numerical score, which is comprised of three (3) separate scores pertaining to the assessed functional, cognitive/behavioral, and skilled care needs of an individual. The functional assessment includes an assessment and corresponding score correlated to the individual's ability to manage medications. The three (3) separate assessment scores are used to determine eligibility for specific LTCSS as follows:
The total numerical score consists of a value from zero to thirty-one (0-31), which may include a score of up to twenty-three (23) on the functional assessment, a score of up to three (3) on the cognitive/behavioral assessment, and a score of up to five (5) on the skilled care needs assessment .
Each face-to-face assessment of an individual using the standardized needs-based assessment tool contains the following components:
The total numerical scores reflect a person's eligibility for LTCSS as follows:
Based on the results of the face-to-face assessment, DHCF or its designated agent shall issue to the individual an assessment determination that specifies his/her required level of care and a corresponding range of LTCSS for which the individual is eligible.
The assessment determination shall include the types of LTCSS available to the person based on the scores received and shall be issued to the person no later than forty-eight (48) hours after the assessment is completed, unless the person's condition necessitates that services be authorized and provided earlier.
For hospital discharges, the timeline for completing the LTCSS assessment, including the issuance of an assessment determination referenced in Subsection 989.13 and the authorization of services included in the determination, shall be forty eight (48) hours from the receipt of a request for an assessment.
An RN or LICSW employed by DHCF or its designated agent shall conduct a face-to-face reassessment of each beneficiary's need for the receipt of LTCSS as follows:
For nursing facility services, DHCF or its designated agent shall conduct utilization reviews at six (6) months and twelve (12) months post admission, and annually thereafter, as follows:
For EPD Waiver services, DHCF may, at its discretion, extend the level of care reauthorization period pursuant to the face-to-face reassessment for a timeframe not to exceed eighteen (18) months to align the assessment date with the beneficiary's Medicaid renewal date.
Requests to conduct re-assessments shall be made in accordance with the requirements under Subsection 989.5.
If an individual meets the required level of care as determined by a numerical score affiliated with each long-term care service in accordance with §989.12, and chooses to participate in a long-term care program, DHCF or its designated agent shall refer the individual to the long-term care service provider of his/her choice.
The individual shall choose a provider based upon the level of care determination and the availability and ability of the provider to safely care for him/her in the setting of the individual's choice.
DHCF or its authorized agent shall maintain the completed standardized assessment tool and documentation reflecting that the person was given a free choice of providers from a list of qualified providers.
If the person has not made a choice, or needs further assistance, DHCF or its authorized agent shall refer the person to the Aging and Disability Resource Center for additional assistance, options counseling, and person-centered planning as appropriate.
If the RN or LICSW employed by DHCF or its designated agent is unable to conduct the face-to-face assessment or reassessment described in this section after making three (3) attempts to do so within five (5) calendar days, an initial Administrative Denial Letter shall be issued to the individual. The initial Administrative Denial Letter shall contain the following information:
If a person currently receiving LTCSS receives an initial Administrative Denial Letter in accordance with § 989.24 and fails to contact DHCF or its agent to request a re-assessment within twenty-one (21) days of the date the letter was issued, a subsequent Administrative Denial Letter shall be issued to the person. The subsequent Administrative Denial Letter shall contain the following information:
DHCF or its designated agent shall issue a Beneficiary Denial or Change of Services Letter if, based upon the assessment or reassessment conducted pursuant to this section, an applicant or beneficiary is determined ineligible, or to not meet the level of care, for LTCSS. The Beneficiary Denial or Change of Services Letter shall contain the following information:
A request for reconsideration of an individual's required level of care as determined by the assessment tool, pursuant to § 989.26(d), must be submitted in writing, by mail, fax, or in person, to DHCF's Office of the Senior Deputy Director/Medicaid Director, within twenty-one (21) calendar days of the date of the notice of denial, termination, or reduction of LTCSS. The request for reconsideration shall include the following information and documentation:
For beneficiaries currently receiving services, a timely filed request for reconsideration will stay the reduction or termination of services until a reconsideration decision is issued.
DHCF shall issue a reconsideration decision no more than forty- five (45) calendar days from the date of receipt of the documentation required in § 989.27.
If DHCF decides to uphold the assessment determination, the reconsideration decision shall contain the following:
A request to appeal the reconsideration decision, pursuant to § 989.30, must be submitted within ninety (90) calendar days of the date of issuance of the reconsideration decision by requesting a fair hearing with OAH in writing, in person, or by telephone, in accordance with 1 DCMR § 2971.
A request to appeal the denial, reduction, or termination of services, pursuant to § 989.26(e), must be submitted within ninety (90) calendar days of the date of the Beneficiary Denial or Change of Services Letter by requesting a fair hearing with OAH in writing, in person, or by telephone, in accordance with 1 DCMR § 2971.
DHCF shall not reduce or terminate LTCSS services while a fair hearing is pending if a beneficiary who was receiving services files the hearing request prior to the effective date of the proposed action to reduce or terminate LTCSS.
DEFINITIONS
When used in this section, the following terms and phrases shall have the meanings ascribed:
Activities of Daily Living - Daily tasks required to maintain an individual's health including eating, bathing, dressing, toileting, grooming, transferring, walking, and continence.
Acuity -The intensity of services required for a Medicaid beneficiary wherein those with a high acuity require more care and those with lower acuity require less care.
Authorized Representative - An individual other than a provider:
Beneficiary - An individual deemed eligible to receive Medicaid services.
Cognitive/Behavioral Functionality- An individual's ability to appropriately acquire and use information, reason, problem solve, complete tasks, and communicate needs; as well as the presence of serious mental illness or intellectual disability, hallucinations or delusions, and verbal or physical behaviors directed at oneself or others.
Contact Attempt -A completed or incomplete telephonic or other person-to-person outreach by DHCF or its designated agent intended to permit communication or information-sharing. Contact attempts may include outbound telephone calls to individuals or their representatives in order to complete contact.
Face-to-Face Assessment -An assessment that is conducted in-person by a Registered Nurse (RN) or Licensed Independent Clinical Social Worker (LICSW) to determine an individual's need for long-term care services.
Informal Supports -Assistance provided by the beneficiary's family member or another individual who is unrelated to the beneficiary.
Level of Care - A threshold determination as to the long-term care services or supports required by an individual.
Non-Medicaid Resources -The individual's utilization of resources including but not limited to, housing assistance, vocational rehabilitation or job help, and transportation.
Person-Centered Planning Process - A process used to assess an individual's needs and options for choices of services that focuses on the individual's strengths, weaknesses, needs, and goals.
Provider- The individual, organization, or corporation, public or private, that provides long-term care services and seeks reimbursement for providing those services under the Medicaid program.
Skilled Care - Medically necessary care ordered by a doctor and provided by or under the supervision of skilled or licensed health care professionals such as nurses and physical therapists. Examples of skilled care include, but are not limited to, physical therapy, occupational therapy, wound care, intravenous injections, and catheter care.
Support Team -A team chosen by the applicant or beneficiary that includes, but is not limited to, the applicant's or beneficiary's family members, friends, community social worker, and/or medical providers.
D.C. Mun. Regs. tit. 29, r. 29-989