DCIS sec 4 39 PASRR

Revision: HCFA-PM-93-1 (BPD) Page 79s

January 1993

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

MEDICAL ASSISTANCE PROGRAM

State:

SECTION 4 - GENERAL PROGRAM ADMINISTRATION (Continued)

Citation

Secs.

1902(a)(28)(D)(i),

and 1919(e)(7), and 1919(b)(3)(E) of

the Act;

P.L. 100-203

(Sec. 4211(c));

P.L. 101-508

(Sec. 4801(b)).

4.39 Preadmission Screening and Annual Resident Review in Nursing Facilities

(a) The Medicaid agency has in effect a written agreement with the State mental health and mental retardation authorities that meet the requirements of 42 CFR 431.621(c).

(b) The State operates a preadmission and annual resident review program that meets the requirements of 42 CFR 483.100-138, and Section 1919(e)(7)(B)(iii) of the Act.

(c) The State identifies NF applicants and residents who are known to, or have indications of possible, serious mental illness, mental retardation, or a related condition, and refers them to the State mental health or mental retardation authority for preadmission screening or resident review according to 42 CFR 483.128(a).

(d) The State does not claim as "medical assistance under the State Plan" the cost of services to individuals who should receive preadmission screening or annual resident review until such individuals are screened or reviewed.

(ed) With the exception of NF services furnished to certain long-term NF residents defined in 42 CFR 483.118(c)(1), the State does not claim as "medical assistance under the State plan" the cost of NF services to individuals who meet the State’s medical necessity criteria for NF, but who are found not to require NF servicesfor whom NF is determined not to be a needed and appropriate setting according to 42 CFR 483.132. Determining appropriate placement considers community and other institutional options.

(f) The State defines minimum criteria, related to the resident assessment process for significant change in a residents physical or mental condition as required at 1919(b)(3)(E) of the Social Security Act, that require nursing facilities to promptly notify the State mental health or mental retardation authority that a resident review as required at section 1919(e)(7)(B)(iii) may be needed for residents with serious mental illness, mental retardation, or a related condition. The State mental health and mental retardation authorities assess notifications from nursing facilities and upon determining that a resident review is needed, will promptly perform a PASRR Level II evaluation and determination.

(ge) ATTACHMENT 4.39-A specifies the State's definition of specialized services.

□ (f) Except for residents identified in 42 CFR 483.118(c)(1), the State mental health or mental retardation authority makes categorical determinations that individuals with certain mental conditions or levels of severity of mental illness would normally require specialized services of such an intensity that a specialized services program could not be delivered by the State in most, if not all, NFs and that a more appropriate placement should be utilized.

(hg) The State applies makes use of categorical determinations, as specified it applies in ATTACHMENT 4.39-BA.