Page 3

TITLE 16 HEALTH AND SAFETY DELAWARE ADMINISTRATIVE CODE 3 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). 20102.2 Medical Necessity Procedures There are two ways to determine the medical necessity of nursing facility care. These are: 20102.2.1 Pre-Admission Screening 20102.2.2 Medical Review Team 20102.2.1 Pre-Admission Screening 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. 20102.2.2 Medical Review Team 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. 1. DMMA is Responsible for PASRR Oversight DMMA will assure PASRR program operates in accordance with federal regulations. 2. A Level I PASRR Screening is completed on all residents or potential residents of a Medicaid certified Nursing home. 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. 3. Determination is made regarding the need for a Level II PASRR screening. 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.