Current through September 21, 2024
(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
(B) Respite care.
(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.
