(a) Purpose. To determine whether an individual with a mental illness has an intellectual disability or related condition which requires, because of the individual's physical and mental condition, the level of services provided by a nursing facility and whether the individual requires specialized services.
(b) Applicability. All individuals who apply for admission to a facility on or after January 1, 1989, or who were clients in a facility on January 1, 1989, are subject to the requirements of this Section if the Level I screening indicates the possibility of mental illness, intellectual disability or related condition. No facility shall admit any individual for whom the Level I screening indicates a reason to refer the individual for a Level II screening until the Level II screening is completed and a determination of appropriate placement rendered.
(c) Change in condition. If there has been a previous Level II and the resident has a change in physical or mental functioning, a new Level II must be requested promptly by the nursing facility. This will be done by completing a new Level I form and submitting it through established procedures. The facility must indicate on the Level I form that a new Level II is being requested because a significant change in the person's physical or mental functioning.
(d) Failure to timely comply with Professional Activities Survey (PAS) requirements. - (i) PAS. Medicaid reimbursement shall be disallowed for nursing facility services furnished to a client before the Level II screening is completed and a determination of appropriate placement in a nursing facility is made.
- (ii) Non-Medicaid individuals. For failure to timely comply with PAS requirements for non-Medicaid eligible individuals, the Department may impose any of the remedies specified in the Rules and Regulations of Wyoming Medicaid, Chapter 5, Long Term Care Facility Remedies, Terminations, using the procedures specified in Chapter 5.
(e) Categorical determinations. A categorical determination takes into account that certain diagnoses, levels of severity of illness, or need for a particular service clearly indicate that admission to or residence in a nursing facility are appropriate without the need for a Level II review and determination. An individual with mental illness, an intellectual disability or related condition who meets the criteria for any category in this section shall be deemed appropriate for nursing home placement. - (i) Terminal illness. A diagnosis of terminal illness constitutes a Level II determination of appropriate placement, and specialized services not required.
- (ii) Severe medical condition. A diagnosis of severe medical condition constitutes a Level II determination of appropriate placement. The individual must meet the following condition: An individual is mentally ill, has an intellectual disability or related condition meets the criteria for "severe medical condition" if he or she is comatose, ventilator dependent, or functioning at the brain stem level, or has been diagnosed by a physician as having chronic obstructive pulmonary disease, severe Parkinson's disease, Huntington's disease, amyotrophic lateral sclerosis, congestive heart failure, severe cardiovascular accident (CVA), quadriplegia, advanced multiple sclerosis, end stage renal disease, severe diabetic neuropathy, or refractory anemia. The illness must result in a level of impairment so severe that the individual could not be expected to benefit from specialized services for mental illness, intellectual disability or related condition.
- (iii) Convalescent care. The individual that is mentally ill has an intellectual disability or related condition and requires a medically prescribed nursing facility stay of no more than one hundred twenty (120) days. After that time, the facility must refer the individual for a Level II. The individual is mentally ill, has an intellectual disability or related condition and has an acute physical illness which:
- (A) Required hospitalization; and
- (B) Does not meet the criteria for an exempt hospital discharge as defined in 42 C.F.R. § 483.106.
- (iv) Provisional placement. The individual requires a nursing facility stay of no more than fourteen (14) days. After that time, the facility must refer the individual for a Level II. The individual is mentally ill, intellectually disabled or related condition and requires admission for:
- (A) Delirium, where an accurate diagnosis cannot be made until the delirium clears; or
- (v) Emergency admissions. The individual is mentally ill, intellectually disabled or a related condition and requires a nursing facility stay of no more than seven (7) days for his or her protection. After that time, the facility must refer the individual for a Level II.
(f) Criteria for Level II screening. - (i) Determination of medical necessity. Each client referred for a Level II screening, regardless of payment source, must be evaluated for medical necessity pursuant to Chapter 22.
- (ii) Level II screening shall be performed using the minimum criteria specified by CMS in §§ 4251 through 4253 of the State Medicaid Manual (SMM), as appropriate for a specific individual. The SMM is published by CMS and is available from CMS or the Department.
- (iii) Determination of appropriate placement. The SMHA or SIDA (as applicable) shall review the mental and physical evaluations and the determinations of medical necessity and determine whether, based on the individual's physical and mental condition, the individual requires the level of services provided by the nursing facility (NF) into which the individual seeks admission.
- (iv) Determination of need for specialized services.
- (A) Mentally ill persons. The need for specialized services for mentally ill persons shall be determined using the procedures and protocols of the SMHA. The procedures and protocols of the SMHA are available from the SMHA or the Department.
- (B) Persons with an intellectual disability. The need for specialized services for persons with an intellectual disability shall be determined using the procedures and protocols of the SIDA. The procedures and protocols are available from SIDA or the Department.
(g) Results of Level II screening. The Level II screening will result in a determination of the appropriateness of nursing facility placement and the need for specialized services. The following outcomes are possible: - (i) Individual requires nursing facility services but does not require specialized services.
- (A) Nursing facility placement is appropriate; and
- (B) Mental health services of a lesser intensity than specialized services may be recommended.
- (ii) Individual requires nursing facility services and specialized services provided in the nursing facility.
- (A) Nursing facility placement is appropriate;
- (B) The State must arrange for provision of specialized services; and
- (C) Persons who do not require nursing facility services but require specialized services and choose to remain in the nursing facility under the thirty (30)-month rule are deemed to require nursing facility services.
- (iii) Individual does not require nursing facility services or specialized services.
- (A) Nursing facility placement is not appropriate or authorized, admission is denied; or
- (B) If the client is already admitted, nursing facility must arrange for orderly discharge, including preparation and orientation of for discharge.
- (iv) Individual does not require nursing facility services but does require specialized services that cannot be provided in the facility.
- (A) Nursing facility placement is not appropriate or authorized, admission is denied; or
- (B) If the client is already admitted, facility must arrange for orderly discharge, including preparation and orientation of for discharge.
- (v) No evidence of serious mental illness and no evidence of an intellectual disability or related condition. Nursing facility placement is authorized.
- (vi) Individual has a primary or secondary diagnosis of dementia without an accompanying condition of an intellectual disability or related condition (if the individual has a diagnosis of an intellectual disability or related condition with dementia, placement is authorized.) Nursing facility placement is authorized.
- (vii) Individual is categorically appropriate due to terminal illness, as described in 42 C.F.R. § 418.3, or severe medical condition. Nursing facility placement is authorized.
- (viii) Evaluation not completed due to death or discharge. PAS not complete. Medicaid reimbursement for nursing facility services will not be authorized.
(h) Notice of Level II determination. - (i) Notice to facility. The Department shall notify the facility, in writing, of the results of each Level II determination; and
- (ii) Notice to individual. The Department shall notify the individual, in writing, of a Level II determination that nursing facility placement is not appropriate. The individual may request a reconsideration regarding the decision that such placement is not appropriate pursuant to the Rules and Regulations of Wyoming Medicaid, Chapter 16, Medicaid Program Integrity.
(i) If a client who has had a Level II within one (1) year is transferred from one nursing facility to another, the transferring facility must copy the Level II documentation and send it with the client as part of the transfer documentation. The admitting facility does not need to complete a Level I or II screening if the client's Level II was completed less than one (1) year before the transfer.
048-19 Wyo. Code R. § 19-7