Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid 600 Washington Street Boston, MA 02111 www.mass.gov/masshealth Eligibility Operations Memo 09-09 June 1, 2009 TO: MassHealth Eligibility Operations Staff FROM: Russ Kulp, Director, MassHealth Operations RE: Clarification of Level-of-Care Conversion Screening Process Introduction The purpose of this memo is to clarify the clinical eligibility screening process, to indicate the difference between nursing facility (formerly known as a long-term approval (LTA)) and short-term clinical eligibility determination screenings and to determine when it is appropriate for MassHealth Enrollment Center (MEC) staff to code cases for long-term care. Background In 2005, the MassHealth Office of Long Term Care (OLTC), with the Executive Office of Elder Affairs, implemented the Comprehensive Screening and Service Model (CSSM) initiative. This program focuses on discharge planning for eligible MassHealth applicants and members currently residing in nursing facilities by setting up community-based services that would allow the person to safely return to living in a noninstitutionalized setting. To facilitate this process, clinicians from MassHealth and the Aging Service Access Points (ASAP) network were instructed by the OLTC to determine nursing facility clinical eligibility and to issue one or more short-term approvals (STA) while the clinician actively works with the nursing facility on the discharge plan for the applicant or member. An institutionalized individual can be issued a series of STAs for as little as a few days or as long as several months. Clinical Eligibility Screenings A MassHealth registered nurse or an ASAP nurse conducts a medical assessment to determine if the applicant or member is in need of nursing facility services and if the stay will be short term or longer. The nurse determines the length of the short-term approval based on the individual’s medical condition. (continued on next page) Clinical Eligibility Screenings (cont.) MassHealth is no longer using the term long term to denote an approval for nursing facility services. Clinical approvals will be for short term or more than six months. If the MassHealth Enrollment Center (MEC) worker receives a nursing facility clinical eligibility approval, the case may be coded for nursing facility services if all other eligibility factors are met. It does not matter what the length of the approval is, as long as it is an approval. MassHealth Enrollment Centers must wait until the clinical eligibility determination notification is received before the applicant can be approved for nursing facility services. Eligibility for nursing facility services payments can never be before the date of clinical eligibility listed on the Nursing Facility Clinical Eligibility form in the box marked “Official Use Only” in the lower left corner of the form. This chart shows the coding result for members for nursing facility services. SC-1 Screening Result Short term Six months+ Six months+ Short term Short term Short term Six months+ Short term Short term Six months+ Six months+ Six months+ Home Maintenance Needs Allowance MassHealth allows a deduction — home maintenance needs allowance (HMNA) — for maintenance of a home when a competent medical authority certifies in writing that a single individual, with no eligible dependents in the home, is likely to return home within six months after the month of admission. This income deduction terminates at the end of the sixth month after the month of admission regardless of the prognosis to return home at that time. In order for the HMNA to be given, the MEC worker must receive a Status Change for a Member in a Long Term Care Facility (SC-1) form with the short-term stay block checked and a physician’s signature, and a clinical eligibility approval stating short-term stay (Block 21on the SC-1 form). (continued on next page) Home Maintenance Needs Allowance (cont.) In the absence of a short-term clinical approval, an HMNA deduction may not be given. This is true even if the SC-1 has a physician’s signature and states that it is a short-term placement. The nurse has determined that this individual will not be rehabilitated within a six-month period and will not be returning to the community within that time. Nursing facilities, applicants or members, or their eligibility representatives (ERDs) may not request that the screening nurse change the nursing facility clinical approval so that the individual can get an HMNA deduction. The HMNA is to be given for a continuous period of institutionalization. If a member returns to the community and remains there for a 30-day period and then reenters a nursing facility for another short-term stay, an HMNA may be given again. There is no limit to the number of HMNAs an applicant or member may receive, as long as there is a break from institutionalization of at least 30 days between stays. If the individual is on a short-term stay and returns home for less than 30 days, a new HMNA may not be given. The previous HMNA would continue until the end of the six-month period, whenever that is. At the time the HMNA ends because the six-month time period has expired, a new clinical eligibility form is not needed. The HMNA deduction is removed and a new patient-paid amount, without the HMNA allowance, is calculated. A patient-paid amount change notice is generated. Short-Term Eligibility Financial Approvals If an individual enters a nursing facility for a short-term stay and he or she is not known to or currently active on MassHealth, a Senior Medical Benefit Request (SMBR), including Supplement A, must be completed and a determination of eligibility must be made by the MEC Intake Unit. When a currently active, single MassHealth Standard- or CommonHealth-eligible community member enters a nursing facility for a short-term stay of six or fewer months, the following process will take place. • The nursing facility sends an SC-1 form that is marked short term and is signed by a physician, along with the clinical eligibility approval form stating short-term approval, to the Short-Term-Care Processing Unit at the Revere MEC. (continued on next page) Short-Term Eligibility Financial Approvals (cont.) • A nursing facility payment segment is established on MMIS for the individual at the nursing facility. • If the member leaves the nursing facility before the end of the six-month period, the long-term care segment is closed. If the six-month short-term period expires and the member is still a patient at the nursing facility or is no longer on a short-term stay, the following process will take place. • The payment segment is closed by the Short-Term-Care Processing Unit worker. • The Short-Term-Care Processing Unit sends the Expiration of Short- Term Stay and Home Maintenance Needs Allowance (ST-CL) cover letter and a Supplement A detailing the need for the supplement to be completed by the nursing facility on behalf of the member. (If the member is under the age of 65, a MER/TRANS form should also be sent to the nursing facility.) The completed forms must be returned to the appropriate MEC with an SC-1 form, stating that the member is transitioning from short term to a stay of more than six months. A new level-of- care determination form is not needed. If this process is not completed by the nursing facility, the member will not be coded for payment. MassHealth Responsibilities Short-Term-Care Processing Unit at Revere MEC •. Create a nursing facility payment segment on MMIS for currently active members. • Close nursing facility segments when the member’s clinical screening is no longer short term. Complete and send an ST-CL to the nursing facility to request a Supplement A and any other applicable forms. • Close the nursing facility segment. Complete and send an ST-CL to the nursing facility to request a Supplement A and any other applicable forms when the HMNA time period expires. MassHealth Enrollment Centers • Determine eligibility for any individual not known to or currently active on MassHealth. • Determine eligibility for married MassHealth members. • Receive and process the SC-1 form, Supplement A, and MER/TRANS forms for members initially coded for short-term stay by the Revere Short-Term-Care Processing Unit. • Process SC-1 forms marked as long term and establish a nursing facility payment segment on MMIS. o Note: Do not send SC-1 forms marked “short term” to the Revere Short-Term-Care Processing Unit for individuals not known to or currently active on MassHealth. (continued on next page) ASAP Responsibilities •. Perform clinical eligibility screening for nursing facility placement. •. Send clinical eligibility screening forms to the appropriate MEC. o Revere Short-Term-Care Processing Unit •. currently active, single MassHealth member on first short-term-care approval o MEC Intake/Ongoing Units •. member is not known to or currently active on MassHealth; or •. member has been in nursing facility longer than six months; or •. member is married Nursing Facility Responsibilities Send SC-1 to appropriate MEC within 10 days when an individual is •. admitted to a nursing facility; • discharged from a nursing facility; • deceased; or • changed from short-term stay to a stay of longer than six months. The nursing facility must also • complete Block 23 on an SC-1 form and ensure physician signs Block 24, if the SC-1 form indicates short-term stay in Block 21; and • ensure appropriate completion of the Supplement A and MER/TRANS forms when a short-term stay expires or changes for a currently active MassHealth member. Attachments Please find attached to this memo the Expiration of Short-Term Stay and Home Maintenance Needs Allowance (ST-CL (05/09)). This form is to be used only by the Short-Term-Care Processing Unit at the Revere MEC. Questions If you have any questions about this memo, please have your MEC designee contact the Policy Hotline. Commonwealth of Massachusetts Executive Office of Health and Human Services www.mass.gov/masshealth Short-Term-Care Processing Unit MassHealth Enrollment Center 300 Ocean Avenue Revere, MA 02151 Nursing Facility Name Nursing Facility Address City/State/Zip Date: Expiration of Short-Term Stay and Home Maintenance Needs Allowance MassHealth ID: was coded for payment to your nursing facility by the Short-Term-Care Processing Unit and given a home maintenance needs allowance (HMNA). The HMNA period of eligibility for this member is exhausted and the payment segment to your facility has been closed effective . In order to determine continued eligibility and receive payment for this individual, the following must be completed and returned to the appropriate MassHealth Enrollment Center (MEC) assigned to your facility within 30 days from the date of this notice. Do not return forms to the Short Term Care Processing Unit. Supplement A new SC-1 form (indicate that the member’s short-term-care stay has terminated in Block 21) Senior Medical Benefit Form (SMBR) MassHealth Eligibility Review Form (MER) A new level-of-care determination is not needed. If the Supplement A and SC-1 forms are not received by the MEC, the member will not be coded for payment to your facility. If you have any questions about this process, please contact the MEC assigned to your facility. DROP DOWN MENU of MECs (names and addresses) MassHealth Enrollment Center, 300 Ocean Avenue, Suite 4000, Revere, MA 02151 1-800-322-1448 MassHealth Enrollment Center, 21 Spring Street, Suite 4, Taunton, MA 02780 1-800-242-1340 MassHealth Enrollment Center, 333 Bridge Street, Springfield, MA 01103 1-800-332-5545 MassHealth Enrollment Center, 367 East Street, Tewksbury, MA 01876 1-800-408-1253 ST-CL (06/09)