PURPOSE: This rule establishes the requirement and procedure for screening by the Division of Aging of Medicaid-eligible and potentially Medicaid-eligible individuals considering long-term care, in order to acquaint them at the earliest possible time with all services available to them, to determine on a preliminary basis their level-of-care need and to permit an effective evaluation by a Division of Aging worker of the resources available in the home, family and community, as required by 42 CFR 456.370(c)(7).

Editor's Note: The secretary of state has determined that the publication of this rule in its entirety would be unduly cumbersome or expensive. The entire text of the material referenced has been filed with the secretary of state. This material may be found at the Office of the Secretary of State or at the headquarters of the agency and is available to any interested person at a cost established by state law.

1. (1) For purpose of this rule only, the following definitions shall apply:

   1. (A) Initial Assessment Form means the Division of Aging form utilized to collect information necessary for a determination of level-of-care need pursuant to 13 CSR 15- 9.030, designated Form DA-124;
   2. (B) Intermediate care facility (ICF) as defined in section 198.006, RSMo;
   3. (C) Long-term care facility means an ICF, a skilled nursing facility (SNF), as defined in section 198.006, RSMo, or a hospital providing skilled or intermediate nursing care in a distinct part under Chapter 197, RSMo;
   4. (D) Make a referral means a contact by telephone, referring the name and address of the potential Medicaid recipient and any other available pertinent information about the potential Medicaid recipient;
   5. (E) Medicaid agency means the single state agency administering or supervising the administration of the Missouri State Medicaid plan;
   6. (F) Medical assistance means benefits provided under section 208.152, RSMo;
   7. (G) Participation in the Medicaid program means the ability and authority to provide services to eligible Medicaid recipients and to receive payment from the Medicaid program for the services;
   8. (H) Potential Medicaid resident means any individual who—a) has already been determined by the Division of Family Services to be eligible for Medical Assistance benefits, b) has applied to the Division of Family Services for Medical Assistance benefits or c) has less than one thousand dollars ($1000) in cash and liquid assets if single or less than two thousand dollars ($2000) in cash and liquid assets if married;
   9. (I) Provider means an SNF, an ICF or a hospital providing skilled or intermediate nursing care in a distinct part under Chapter 197, RSMo which has been certified to participate in the Medicaid program;
   10. (J) Resident as defined in section 198.006, RSMo; and
   11. (K) Skilled nursing facility, or SNF, as defined in section 198.006, RSMo.

2. (2) All providers shall make a referral to the toll-free Division of Aging hotline (1-800- 392-0210) within one (1) working day after the facility is initially contacted by or on behalf of a potential Medicaid resident unless the potential Medicaid resident is, at the time of the initial contact—

   1. (A) Residing in another long-term care facility as a Medicaid resident;
   2. (B) In a hospital and had been in a longterm care facility as a Medicaid resident immediately prior to the hospitalization;
   3. (C) In a hospital and hospital staff can document they have made a referral to the Division of Aging;
   4. (D) Residing in a state hospital for the mentally ill operated under Chapter 630, RSMo or a state habilitation center operated under Chapter 630, RSMo; and
   5. (E) A child (seventeen (17) years of age or under).

3. (3) In order to document that referrals to the Division of Aging have been made as required by this rule, providers shall provide the following information, with regard to each resident applying for Medicaid benefits, on the Initial Assessment Form:

   1. (A) The date the provider was initially contacted by or on behalf of the resident concerning admission to an long-term care facility;
   2. (B) The date the resident was initially admitted to the provider’s facility;
   3. (C) The date a referral was made to the Division of Aging and the screening referral number assigned by the Division of Aging hotline when the referral was made; and
   4. (D) If the provider did not make a referral to the Division of Aging, an explanation of why no referral was made.
4. (4) When the provider makes a referral to the Division of Aging, the Division of Aging will contact the potential Medicaid resident or his/her guardian within five (5) working days of the date of the referral. The Division of Aging will provide the potential Medicaid resident with information regarding services available to meet the individual’s needs in the home, if the services are available and with information regarding long-term care facilities. If the individual or his/her guardian wishes to receive services in a home-based setting, the Division of Aging will evaluate the individual to determine the potential availability of alternative services and advise the individual or guardian that if s/he wish to obtain financial assistance for these services, s/he will need to apply for Title XIX benefits at the respective County Division of Family Services Office. Once the application is made, services may be authorized by the Division of Aging. If the individual or his/her guardian has no objection, the individual’s relatives and other significant persons, including the attending physician, may be included in discussions. If the person wants to enter an long-term care facility s/he will be given a Division of Aging DA-13 form with documentation of the screening referral number to give to the provider to verify that alternatives to long-term care facility care have been presented.
5. (5) The Medicaid agency may terminate or suspend the participation in the Medicaid program of a provider determined to have demonstrated a consistent pattern or practice of failing to comply with this rule. The Medicaid agency shall offer a provider the opportunity for a hearing as required by 42 CFR sections 431.151—431.154.
6. (6) The Medicaid agency may withhold or recoup Medicaid payments to a provider for services provided to a resident from the time of admission to a provider’s facility until the recipient is determined eligible for ICF or SNF level-of-care if the provider failed to make a referral of that resident to the Division of Aging as required by this rule. This recoupment or withholding shall be accomplished utilizing the procedures, and after providing prior notice to the provider, set out at 13 CSR 70-3.030(5) and 13 CSR 70-10.005(9). Providers from whom payments have been withheld or recouped pursuant to this section shall not charge or attempt to charge the resident or his/her responsible party for the amount withheld or recouped by the Medicaid agency.
7. (7) The Medicaid agency shall not impose the sanctions provided for in section (5) or withhold or recoup in accordance with section (6) of this rule as a result of any failure to make a referral where the provider made a good faith effort to determine whether the resident 13 CSR 15-9

in question was a potential Medicaid resident but received incorrect or incomplete information.

AUTHORITY: sections 207.020 and 208.159, RSMo 1986 and 208.153, RSMo Supp. 1991.* This rule was previously filed as 13 CSR 40-81.086. Emergency rule filed March 14, 1984, effective April 12, 1984, expired Aug. 8, 1984. Original rule filed March 14, 1984, effective Aug. 9, 1984. Amended: Filed Aug. 3, 1992, effective May 6, 1993.

*Original authority: 207.020, RSMo 1945, amended 1961, 1965, 1977, 1981, 1982, 1986; 208.159, RSMo 1979; and 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991.