Current through Register Vol. 18, September 20, 2024
(1) This rule provides the preadmission
screening requirements of the Montana medicaid program for applicants to
nursing facilities participating in the Montana medicaid program.
(2) Nursing facility applicants must undergo
a level I screening prior to admission to a nursing facility.
(a) A level I screening may result in the
following determinations which will apply as indicated:
(i) a nursing facility applicant who has no
diagnosis or any indications of mental retardation or mental illness will:
(A) if not a medicaid recipient, receive a
copy of the level I screen. No further action will be taken by the department;
and
(B) if a medicaid recipient,
undergo a level of care determination for nursing facility services.
(ii) a nursing facility applicant
who has a diagnosis or indications of mental retardation or mental illness will
be referred to either the state mental health authority or the mental
retardation authority for a level II screening unless determined by the level I
screening to be within one of the exceptions provided for in (3) (a) of this
rule.
(3) A
nursing facility applicant who has a diagnosis or indications of mental
retardation or mental illness may enter a nursing facility only if the
applicant is determined to be in need of nursing facility services and is
allowed to enter as provided for in (3) (a) or (b) of this rule;
(a) A person with a diagnosis or indications
of mental retardation or mental illness who is in need of nursing facility
services may enter a nursing facility without a level II screening or a
determination of appropriate active treatment, if either:
(i) the person is being discharged from an
acute care facility and admitted to a nursing facility for recovery from an
illness or surgery for a period not to exceed 120 days and is not a danger to
self or others;
(ii) the person is
certified by a physician to be terminally ill (prognosis of a life expectancy
of six months or less) and is not a danger to self or others;
(iii) the person is comatose, ventilator
dependent, functioning at the brain stem level or diagnosed as having chronic
obstructive pulmonary disease, severe Parkinson's disease, Huntington's Chorea,
amyotrophic lateral schlerosis, congestive heart failure or other similar
diagnosis which prohibits the person from participating in active treatment;
or
(iv) the person has a primary
diagnosis of dementia, including Alzheimer's disease or a related disorder,
based on a neurological examination.
(b) A level II screening may result in the
following determinations which will apply as indicated:
(i) Any person with mental retardation or
mental illness determined not to be in need of nursing facility services,
whether or not active treatment services are required, shall be considered
inappropriate for placement or continued residence in a nursing
facility;
(ii) Any person with
mental retardation or mental illness determined to be in need of active
treatment services shall be considered inappropriate for placement or continued
residence in a nursing facility;
(iii) Any person with mental retardation or
mental illness determined to be in need of nursing facility services but not to
be in need of active treatment services shall be considered appropriate for
placement or continued residence in a nursing facility;
(iv) Any person with mental retardation or
mental illness determined to be in need of both nursing facility services and
active treatment, who is of advanced years, competent to make an independent
decision and who is not a danger to self or others shall be considered
appropriate for placement or continued residence in a nursing facility if the
person so chooses.
(4) Medicaid recipients must be determined by
a preadmission screening team to require nursing facility services before
medicaid payment for services in a nursing facility or the home and community
services program will be authorized.
(a) If a
person is medicaid eligible prior to admission to a nursing facility, a nursing
facility screening must be requested prior to admission. Payment for nursing
facility care shall be effective on the date of entry to the nursing facility
if the applicant meets all eligibility requirements.
(b) If the person applies for medicaid while
a resident of a nursing facility, the nursing facility screening must be done
prior to initial medicaid payment. Payment shall be effective on the date of
the nursing facility screening or the date of referral to the preadmission
screening team, whichever is earlier.
(5) Retroactive approval for nursing facility
services is available only if:
(a) the
applicant is determined to be financially eligible for medicaid during the
retroactive period; and
(b) the
applicant had undergone a determination of need for nursing facility services
either by the preadmission screening team or for purposes of medicare payment;
and
(c) the applicant was
determined to be in need of nursing facility services as a result of the
screenings.
(6) A
nursing facility applicant who is not a medicaid recipient may request that a
nursing facility screening be conducted. This screening will be performed by
the preadmission screening team.
(7) Preadmission screening will be performed
by persons the department determines are qualified to conduct the various
elements of the screening.
(8) A
nursing facility admitting a nursing facility applicant for whom a level I
screening or a nursing facility screening has not been conducted may be subject
to the sanctions provided at ARM
37.85.502 and to any other
measures that federal or state authorities deem appropriate and necessary for
the purposes of the federal Social Security Act.
Sec.
53-6-113
and
53-2-201,
MCA; IMP, Sec.
53-2-201,
53-6-101,
53-6-141 and
53-6-402,
MCA;
