Wyo. Code R. 048-0037-19
Medicaid
Chapter 19: Nursing Facility Preadmission Screenings
Effective Date: 11/29/1990 to 08/01/1995
Rule Type: Superceded Rules & Regulations
Reference Number: 048.0037.19.11291990
Date Filed 11/29/90 Expr Date
Supr Date Repeal Date
Document Type RULES
PREADMISSION SCREENINGS
These rules are promulgated by the Department of Health pursuant to the Medical Assistance and Services Act at W.S. 42-4-101 et seq. and the Wyoming Administrative Procedures Act at W.S. 16-3-101 et seq.
This rule establishes methods and standards for preadmission screening and resident reviews of patients and prospective patients of facilities. The requirements of this rule apply to all patients and prospective patients, regardless of payment source.
Section 3. General terms. This rule is intended to implement and be read in conjunction with the provisions of Pub. L. 100-203, Subtitle B, Part 2, 101 Stat. 1330-182 through 1330-221, the rules and regulations promulgated by HCFA thereunder and Chapter XXII of the Medicaid Rules.
(a) "Active treatment." Active treatment for individuals with mental retardation or related conditions or active treatment for individuals with mental illness.
(b) "Active treatment for individuals with mental illness." The implementation of an individualized plan of care which:
(i) Is developed under the supervision of a physician;
(ii) Prescribes specific therapies and activities for the treatment of an individual that is experiencing an acute episode of severe mental illness; and
(iii) Is implemented by a physician or other qualified mental health professional.
(c) "Active treatment for individuals with mental retardation or related conditions." A continuous program for a patient which includes aggressive, consistent implementation of a program of specialized and generic training: treatment, health services and related services that are directed toward the objective specified in paragraphs (i) and (ii). Such a program excludes services to maintain generally independent patients who are able to function with little supervision or the absence of a continuous active treatment program.
(i) Acquisition of the behaviors necessary for the patient to function with as much self determination and independence as possible; and
(ii) Prevention or deceleration of regression or loss of current optimal functional status.
(d) 'Admission.' The act that allows an individual to officially enter a facility to receive nursing facility services.
(e) 'Alzheimer's disease.' An individual with a primary diagnosis of dementia, including Alzheimer's disease or a related disorder, as defined by the DSM III-R.
(f) 'Annual' or 'annually.' On or before the same day of the same month of the following calendar year.
(g) 'Applicant.' A person whose written application for Medicaid has been submitted to the Division of Public Assistance and Social Services, or its successor, or the Social Security Administration, but has not received final action.
(h) 'Appropriate placement.' The placement of an individual in a treatment setting when the individual's needs meet the minimum standards for admission to that treatment setting and the individual's needs for treatment do not exceed the level of services which the treatment setting is capable of providing.
(i) 'Chemically dependent.' An individual with a diagnosis of chemical dependency as defined by the ICD-9-CM.
(j) 'Classification in Mental Retardation.' The Classification in Mental Retardation (1983 ed.) of the American Association on Mental Deficiency, which is hereby incorporated by reference. The book is published by the American Association on Mental Deficiency in Washington, D.C., and is available from the publisher.
(k) 'Convalescent care.' Medically prescribed nursing facility services provided to a person that is mentally ill or mentally retarded for up to 120 days after release from a hospital.
(l) 'Date of admission.' The date an individual enters a facility and begins receiving nursing facility services.
(m) 'DCP.' The Division of Community Programs of the Department, its agent or designee.
(n) 'Dementia.' A primary diagnosis of dementia as defined in the DSM III-R.
(o) 'Department.' The Wyoming Department of Health, its agent, designee or successor.
(p) 'DSM III-R.' The Diagnostic and Statistical Manual of the American Psychiatric Association III-R (3rd edition), which is hereby incorporated by reference. The DSM III-R is published by the American Psychiatric Association, Washington, D.C., and is available from the publisher.
(q) 'Facility.' A skilled nursing facility (SNF), an intermediate care facility (ICF) or a nursing facility that meets all of the requirements of state licensure and certification for participation in the Medicaid program. 'Facility' may include a distinct part of a hospital or institution which is designated to provide nursing facility services.
(r) 'HCFA.' The Health Care Financing Administration of HHS or its designee.
(s) 'HHS.' The United States Department of Health and Human Services.
(t) 'Hospital.' An institution that: (1) is approved to participate as a hospital under Medicare; (2) is maintained primarily for the treatment and care of patients with disorders other than mental diseases or tuberculosis; and 3) is licensed to operate as a hospital by the State of Wyoming or, if the institution is out-of-state, licensed by the state in which the institution is located.
(u) 'ICD-9-CM.' The International Classification of Diseases (9th Revision) Clinical Modification, which is hereby incorporated by reference. The ICD-9-CM is published by HCFA and is available from the United States Government Printing Office, Washington, D.C. 20402.
(v) 'IMD.' An institution for mental diseases as defined by 42 C.F.R. 435.1009, which is hereby incorporated by reference.
(w) 'IMD services.' Services that meet the standards of 42 C.F.R. Part 441 Subpart C, which are hereby incorporated by reference.
(x) 'Inpatient psychiatric hospital services.' Services that meet the standards of 42 C.F.R. Part 441 Subpart D, which are hereby incorporated by reference.
(y) 'Intermediate care.' Intermediate care as defined in 42 C.F.R. 440.150 (1988), which is hereby incorporated by reference.
(z) 'Medicaid.' Medical assistance and services provided pursuant to Title XIX of the Social Security Act and the Wyoming Medical Assistance and Services Act.
(aa) 'Medically necessary.' Intermediate care, skilled nursing care or nursing facility care that is required because of an individual's functional ability as determined pursuant to this rule.
(bb) 'Medicare.' The health insurance program for the blind, aged and disabled established pursuant to Title XVIII of the Social Security Act.
(cc) 'Mentally ill or mental illness.' An individual that has a current primary or secondary diagnosis of one of the following major mental disorders as defined by the DSM III-R: schizophrenia, paranoia, major affective disorder, schizoaffective disorder or atypical psychosis. A person with a primary diagnosis of dementia, including Alzheimer's disease or a related disorder, is not mentally ill for purposes of this Chapter.
(dd) 'Mentally retarded or mental retardation.' An individual with mild, moderate, severe or profound retardation as defined by the Classification in Mental Retardation, or a person with a related condition.
(ee) 'Nursing facility.' A nursing facility as defined by section 1919 of the Social Security Act (Pub. L. 100-203 section 4211(a)).
(ff) 'Nursing facility services.' ICF services as defined in 42 U.S.C. 1396d(d), SNF services as defined in 42 U.S.C. 1396d(f), or nursing facility services as defined by section 1919 of the Social Security Act (Pub. L. 100-203 Section 4211).
(gg) 'Organic brain syndrome or a related condition.' Organic brain syndrome or a related condition as defined in the ICD-9-CM.
(hh) 'PASARR.' Preadmission screening and annual resident review.
(ii) 'Patient.' A resident of a facility.
(jj) 'Person with a related condition.' An individual that has a severe, chronic disability that meets all of the following conditions:
(i) It is attributable to:
(A) Cerebral palsy or epilepsy; or
(B) Any other condition, other than mental illness, found to be closely related to mental retardation because this condition results in impairment of general intellectual functioning or adaptive behavior similar to that of persons with mental retardation, and requires treatment or services similar to those required for these persons;
(ii) It is manifested before the person reaches age twenty-two;
(iii) It is likely to continue indefinitely; and
(iv) It results in substantial functional limitations in three or more of the following areas of major life activity:
(A) Self Care;
(B) Understanding and use of language;
(C) Learning;
(D) Mobility;
(E) Self-direction; and
(F) Capacity for independent living.
(kk) 'Physician.' A person licensed to practice medicine or osteopathy by the Wyoming State Board of Medical Examiners or a comparable agency in another state.
(ll) 'Provider.' A facility which has a current provider agreement with the Department.
(mm) 'Provider agreement.' A formal written agreement between the Department and a facility certified to provide services to recipients.
(nn) 'Recipient.' An individual that has been determined eligible for Medicaid.
(oo) 'Severe medical condition.' An individual that is:
(i) Mentally ill or mentally retarded; and (ii) Comatose, ventilator dependent, functions 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 or congestive heart failure.
(pp) "Skilled nursing care." Skilled nursing care as defined in 42 C.F.R. 440.40 (1988), which is hereby incorporated by reference.
(qq) "State mental health authority." The individual or entity within the DCP which has been designated as the state mental health authority.
(rr) "State mental retardation authority." The individual or entity within the DCP which has been designated as the state mental retardation authority.
(ss) "Terminally ill." An individual that:
Section 5. Admission of mentally ill or mentally retarded patients.
(a) Mentally ill individuals. Except as otherwise provided by this Section, a facility shall not admit any mentally ill individual unless:
(i) The state mental health authority has determined, based on a physical and mental evaluation performed by a person or entity other than the state mental health authority prior to admission, that the individual requires nursing facility services because of his or her physical and mental condition; and
(ii) If the individual requires nursing facility services, the state mental health authority has determined whether the individual requires active treatment.
(b) Mentally retarded individuals or persons with related conditions. Except as otherwise provided by this Section, a facility shall not admit any patient who is mentally retarded or any person with a related condition unless:
(i) The state mental retardation authority has determined that the individual requires nursing facility services because of his or her physical and mental condition; and
(ii) If the individual requires nursing facility services, the state mental retardation authority has determined whether the individual requires active treatment.
(c) Persons not subject to Section 7. The admission of an individual with one of the following conditions is not subject to the comprehensive requirements of Section 7. An individual that:
(i) Has a diagnosis of primary degenerative dementia (Alzheimer's or related disorders);
(ii) Has a terminal illness, is not a danger to himself or other persons, and has a life expectancy of six months or less;
(iii) Requires convalescent care. If an individual requiring convalescent care remains in a facility for more than 120 days, the individual must undergo a new Level I screening pursuant to Section 6 and is subject to the requirements of Section 7; or
(iv) Has severe medical conditions.
(a) Purpose. The Level I screening is to determine whether an individual seeking admission to or residing in a facility needs further evaluation because of suspected mental illness, mental retardation or related disorders.
(b) Applicability. All individuals who apply for admission to a facility on or after January 1, 1989, or who were patients in a facility on January 1, 1989, are subject to the requirements of this Section.
(c) Frequency of screening.
(i) Any individual seeking admission to a facility on or after January 1, 1989, must be screened before admission, and annually thereafter.
(ii) Any individual who was a patient in a facility before January 1, 1989, must be screened on or before April 1, 1990, and annually thereafter.
(d) Screening. All screening shall be performed by the facility, except as otherwise specified by the Department, using the following criteria:
(i) Mental illness. The screener shall consider whether:
(A) The individual is diagnosed as mentally ill by a physician or qualified mental health professional;
(B) The individual has any recent history (within the last two years) of having been diagnosed as mentally ill or has had a major tranquilizer prescribed on a regular basis in the absence of a neurologic disorder;
(C) There is any presenting evidence of a mental illness, other than a diagnosis of Alzheimer's disease or dementia, including possible disturbances in orientation, affect or mood; and
(D) The individual has a primary diagnosis of Alzheimer's disease or dementia.
(ii) Mental retardation. The screener shall consider whether:
(A) The individual is diagnosed as mentally retarded by a physician or qualified mental retardation professional;
(B) The individual has a history of mental retardation or developmental disability;
(C) There is any presenting evidence, cognition or behavior functions, that may indicate the individual has mental retardation or developmental disability; and
(D) The individual was referred by an agency that serves persons with mental retardation or developmental disability, and whether the individual was eligible for that agency's services.
(iii) Other considerations. The screener shall also consider whether the individual:
(A) Has a terminal illness;
(B) Has severe medical conditions; or
(C) Requires convalescent care.
(e) Recommendation. Upon completion of the screening, the screener shall make a recommendation as to whether the individual should be referred for a Level II screening:
(i) If the recommendation is that a Level II screening is not necessary, the individual may be admitted to the facility; or
(ii) If the recommendation is that a Level II screening is necessary, the provisions of Section 7 shall apply.
(f) Documentation requirements. The facility shall complete documentation in the format and in the quantity specified by the Department.
(a) Purpose. To determine whether an individual that is mentally ill or mentally retarded requires, because of the individual's physical and mental condition, the level of services provided by a nursing facility, and whether the individual requires active treatment.
(b) Applicability. All individuals who apply for admission to a facility on or after January 1, 1989, or who were patients in a facility on January 1, 1989, are subject to the requirements of this Section if the Level I screener or the Department recommends a Level II screening.
(c) Screening criteria. The Department shall perform Level II screening using the minimum criteria specified by HCFA in 4251 through 4253 of the State Medicaid Manual (5/89), as appropriate for a specific individual. Sections 4251 through 4253 of The State Medicaid Manual are hereby incorporated by reference. The State Medicaid Manual is published by HCFA and is available from HCFA or the Department.
(d) Results of Level II screening.
(i) May be admitted to a nursing facility. An individual that is mentally ill or mentally retarded who requires the level of services provided by a nursing facility, whether or not he or she also requires active treatment, may be admitted to a nursing facility if that is an appropriate placement.
(ii) May not be admitted to a nursing facility. An individual that is mentally ill or mentally retarded who does not require the level of services provided by a nursing facility, regardless of whether or not he or she needs active treatment, should be considered inappropriate for placement and may not be admitted.
(iii) May be considered appropriate for continued placement in a nursing facility. A resident that is mentally ill or mentally retarded who requires the level of services provided by a nursing facility, regardless of the length of his or her previous stay or whether he or she needs active treatment, may continue to reside in the facility if that is an appropriate placement.
(iv) May choose to remain in the nursing facility even though placement would otherwise be considered inappropriate. A resident that is mentally or mentally retarded who does not require the level of services provided by a nursing facility but does require active treatment and who has resided in a nursing facility for at least thirty months may choose to continue to reside in the facility or he or she may choose to receive covered services in an alternative appropriate institutional or noninstitutional setting.
(v) May not be considered appropriate for continued placement and must be discharged. A resident that is mentally ill or mentally retarded who does not require the level of services provided by a nursing facility but does require active treatment and who has resided in the facility less than thirty months must be discharged.
(vi) May not be considered appropriate for continued placement in a nursing facility and must be discharged. A resident that is mentally ill or mentally retarded, even though he or she has resided in the nursing facility for thirty months or more, who requires neither nursing facility services nor active treatment must be discharged.
(e) Referral for appropriate placement. If the results of the screening indicate that placement in a nursing facility is not appropriate and the individual requires active treatment, the facility shall refer the individual to an appropriate placement, except as otherwise provided in (d).
(f) Alternative disposition plans. For those residents of a nursing facility who are mentally retarded or mentally ill and who are determined not to require the level of services of a nursing facility but require active treatment, the Department and HHS have entered into an agreement relating to the disposition of such residents of the facility. That agreement, which was approved on March 26, 1989, provides for alternative disposition plans and is hereby incorporated by reference. Copies of the agreement are available from Medical Assistance Services of the Department.
(g) Notice of Level II determination. The Department shall notify the facility of the results of all Level II determinations. The Department shall notify the individual or patient of a Level II determination that nursing facility placement is inappropriate. The individual may request a reconsideration of that decision pursuant to Section 9.
(a) Completion of screening. No facility shall receive Medicaid reimbursement for nursing facility services provided to a recipient until:
(i) The completion of the Level I screening which indicates that nursing facility services are appropriate and that there is no need for Level II screening; or, if the Level I screening indicates the need for Level II screening, the completion of the Level II screening which indicates that nursing facility services are appropriate; and
(ii) The completion of a long term care determination pursuant to Chapter XXII which indicates that nursing facility services are medically necessary.
(i) For recipients that do not require Level II screening, Medicaid reimbursement shall commence upon receipt by the Department of the results of the Level I screening indicating that there is no need for a Level II screening and that nursing facility services are appropriate. Reimbursement shall be retroactive to the date of the completion of the Level I screening, provided there was a timely level of care referral pursuant to Chapter XXII, subsection 5(g), of these rules.
(ii) For recipients that required Level II screening, Medicaid reimbursement shall commence upon the completion of the Level II screening which indicates that nursing facility services are appropriate, except as specified in Section 7. Reimbursement shall be retroactive to the date of the completion of the Level II screening, provided there was a timely level of care referral pursuant to Chapter XXII, section 5(h), of these rules. Payments for residents permitted to continue to reside in a facility pursuant to Section 7(d)(iv) are subject to the provisions of this paragraph except that such payments shall be contingent upon the completion of a Level II screening, regardless of whether the screening indicates that nursing facility services are appropriate.
(a) Request for reconsideration. An applicant or patient may request that the Department reconsider a determination that nursing facility services are not appropriate or medically necessary. Such request must be mailed to the Department by certified mail within thirty days of the date the Department mails notice pursuant to subsection 7(g). The request must state with specificity the reasons for the request. Failure to provide such a statement shall result in the dismissal of the request with prejudice.
(b) Reconsideration. The Department shall review the decision and send written notice to the individual of its final decision within forty-five days after receipt of the request for reconsideration. The Department may request additional information from the individual or screening agency as part of the reconsideration process.
(c) Administrative hearing. An individual may request an administrative hearing regarding the final decision pursuant to Chapter I of these rules by mailing by certified mail or personally delivering a request for hearing to the Department within twenty days of the date the individual receives notice of the final decision. The request for hearing must comply with the requirements of Chapter I.
(d) Continuation of Medicaid payments. Medicaid payments for a recipient shall continue pending the final decision after a request for reconsideration and pending a final decision after a request for an administrative hearing.
Section 10. Severability. If any portion of these rules is found to be invalid or unenforceable, the remainder shall continue in effect.