Commonwealth of Massachusetts
Executive Office of Health and Human Services
Office of Medicaid
600 Washington Street
Boston, MA  02111
www.mass.gov/masshealth	
	MassHealth
	Acute Inpatient Hospital 
	   Bulletin 128
	May 2004

	TO:	Acute Inpatient Hospitals Participating in MassHealth

	FROM:	Beth Waldman, Medicaid Director 

	RE:	Revisions to the Nursing Facility Preadmission Process

Introduction	This bulletin provides a detailed description of procedural changes concerning the roles and responsibilities of acute inpatient hospitals (AIHs) as they relate to the nursing-facility clinical-eligibility screening process for MassHealth members and applicants.  These revisions are effective June 1, 2004.

Current Process	AIHs determine nursing-facility clinical eligibility for MassHealth-only 
	members, MassHealth applicants, and the dually eligible population (those with Medicare and Medicaid). The Request for Services (RFS), MDS-HC, and eligibility/OBRA/PASARR forms are completed and used by the AIH to determine clinical eligibility for nursing-facility services.   The hospital may grant short-term eligibility authorizations for up to 90 days or, under limited circumstances, a long-term approval.  The documents are then forwarded to the local Aging Service Access Point (ASAP) along with the AIH notice of clinical eligibility. The AIH issues the Notice of Clinical Eligibility to the member/applicant and to the nursing facility.  The AIH discharges the patient to the nursing facility per current protocol.  The ASAP provides an administrative review of this documentation.

What Is Changing	The AIH will continue to determine clinical eligibility for nursing-facility services for the following populations:  MassHealth-only, MassHealth applicants with no other primary payer source for NF services (that is, the uninsured), and for MassHealth applicants and dually eligible individuals when there is a nonqualifying Medicare hospital stay (less than three days).  However, under this new process, short-term approvals granted by AIHs will be for only 45 days of nursing-facility services, rather than for up to 90 days.  AIHs will continue to grant long-term approvals under the limited circumstances, as described in the current guidelines.

(See attachment: revised AIH Admission Notice.  You may make copies of this notice, or may contact MassHealth Provider Services for additional copies.  The address is provided at the end of this bulletin.)
	
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What Is Changing	AIHs will no longer determine nursing-facility clinical eligibility for 
(cont.)			MassHealth applicants or dually eligible members.  These populations will receive Medicare reimbursement or another primary insurer’s reimbursement for nursing-facility services on admission to the nursing facility.  

AIHs will transfer these individuals to nursing facilities without a clinical screening or notice of clinical eligibility from MassHealth.  For those MassHealth members who are dually eligible, MassHealth will continue to cover the appropriate nursing-facility coinsurance and deductibles.  The nursing-facility coinsurance and deductible payments from MassHealth do not require clinical eligibility.

What Is Not Changing	AIHs will continue to determine nursing-facility clinical eligibility for Medicaid-only MassHealth members, and individuals who at the time of hospital discharge have no nursing facility payer source and for whom MassHealth will be the sole source of payment for the nursing facility from the first day of admission.

	The OBRA/PASARR screening for all individuals seeking admission to a nursing facility remains the same.  All individuals, regardless of payment source, seeking admission to a nursing facility must be reviewed for the need of a Level II PAS before admission.  If an individual requires a Level II PAS, the hospital must notify DMR or DMH/HES. The Level II PAS must be completed and the individual determined clinically eligible for nursing-facility services before admission.  Where applicable, attach the findings to the Notice of Eligibility.

Questions	If you have any questions about the information in this bulletin, please contact MassHealth Provider Services at 617-628‑4141 or 1‑800‑325‑5231.   For additional copies of the revised AIH Admission Notice, you must  make your request in writing.  Include your provider number, address, and telephone number, and the exact title of the form.
Send it to the following address.

		MassHealth
Forms Distribution
P.O. Box 9101
Somerville, MA  02145
617-576-4087 (fax)
703-917-4937 (fax)