8114.2 Level of Care Threshold

Verification that the beneficiary has met necessary level of care is required. For the majority of individuals, KDADS will compute a Level of Care score and document the determination on the online ES-3164. This will be completed within 10 working days of receiving the request for the determination. However, for persons referred for a Level II evaluation, no LOC score will be computed. Appropriateness of placement is determined by the Level II evaluation, which override, any Level I score. The Level I score will not be communicated if a Level II has been completed. A Level II evaluation may find the individual is approved for a limited stay only. In these situations, payment is approved for the duration of the limited stay only. Medicaid reimbursement terminates at the end of the period unless a subsequent screen provides for extended payment. A new online ES-3164 must be sent to the KDADS CARE Coordinator to determine if a new assessment has been completed. The request is initiated 10-days prior to the expiration of the limited stay.

Persons with a Level II approval may be served in an NF or NF MH. However, a Level II evaluation must be completed indicating a need for MH level of care prior to approval for an NF MH placement. Persons without an appropriate Level II finding are not eligible in an NF MH.

The following persons are exempt from a LOC determination:

Special Admissions - Persons entering an NF for a stay expected to be 30 days or less due to CARE exception listed in the KDADS Level I CARE Manual section noted above are also exempt from the LOC threshold requirement. A physician's statement documenting the anticipated length of stay is on file with the facility and must be included with the MS-2126, Notification of Facility Admission/Discharge form. For these situations only, failure to meet the LOC threshold or failure to receive a CARE does not impact eligibility for reimbursement of services. However, coverage beyond day 30 cannot be approved unless the LOC threshold is met.

Persons exempt from a CARE because of previous residence in an NF are also exempt from an LOC determination unless the previous facility was located out of state or an LOC score has not previously been obtained.

Emergency Admissions - The CARE assessment is delayed for admittance to an NF based on an emergency listed in the KDADS Level I CARE Manual section noted above. KDADS will report any emergency admission using the ES-3164 on the online CARE Inquiry system. Persons remaining in the facility beyond the length of the emergency admission must have a completed CARE for payment to continue. Failure to ultimately obtain the CARE does not impact payment eligibility for the emergency admission period. This is true even if the individual does not meet LOC requirements.

Individuals diagnosed with a terminal illness to qualify for hospice care and individuals in a coma or persistent vegetative state are exempt from CARE and therefore, exempt form an LOC determination. This exemption is based on a determination by KDADS.

If the client was assessed as appropriate for NF Level of CARE, the client may choose to receive NF care, HCBS or PACE (if available). If the individual chooses NF placement, financial eligibility shall be determined using procedures outlined in 8172 .

If an individual residing in an NF does not meet the necessary criteria because a current CARE has not been completed or level of care is not met, financial eligibility is determined according to the procedures outlined in 8171 .