To be eligible for Medicaid, applicants must meet two requirements: financial requirements and medical requirements. I’ve posted many articles on this blog over the years discussing the financial requirements of the Medicaid program in New Jersey, and offering various strategies to accelerate financial eligibility for the program. However, I have surprising few posts discussing Medicaid’s medical requirements. This blog post is meant to correct that. The post briefly describes the medical requirements of the Medicaid program, and discusses the tools used by program administrators to determine if an applicant meets those requirements.

In order to meet Medicaid’s medical requirements, an applicant must show that he or she has a need for long-term care services. To make this showing, the applicant must submit to a Pre-Admission Screening program. Pre-Admission Screening ensures that nursing home residents actually need a nursing home level of care and helps to avoid inappropriate placements that are harmful to those placed in a nursing home and deprive access to others who truly need nursing home services. NJS 30:4D-17.10. 

Under federal law, a nursing home must assess the resident’s capabilities no later than 14 days after the resident’s admission to the nursing home. 42 USC §1396r(b)(3)(C)(i)(I). The assessment is a comprehensive and standardized assessment of each resident’s “functional capacity.” 42 USC §1396r(b)(3)(A). It identifies “significant impairments in functional capacity” and a resident’s ability to perform “daily life functions.” 42 USC §1396r(b)(3)(A)(i). The assessment must use a “uniform minimum data set” which is a specified set of common elements and definitions. 42 USC §1396r(b)(3)(A). Federal regulations require that a comprehensive resident assessment be completed using an assessment tool specified by the State that includes a review of the resident’s health and treatment regimens. 42 CFR §483.20(b). 

The assessments required by federal laws must be coordinated “with any State-required preadmission screening program to the maximum extent practicable in order to avoid duplicative testing and effort.” 42 USC §1396r(b)(3)(E). New Jersey Medicaid laws have established a Pre-Admission Screening program through a law entitled the Pre-Admission Screen Act, NJS 30:4D-17.10. New Jersey’s Pre-Admission Screen Act defines a Pre-Admission Screening as “an assessment of the individual’s need for care in a skilled nursing or intermediate care facility, the preparation of an initial care plan and the arrangement for needed services.”  NJS 30:4D-17.11(c). The nursing facility cannot admit an individual without first insuring that a Pre-Admission Screening is performed, if the individual is eligible for Medicaid when he or she applies for residency or may become eligible for Medicaid within six months of admission. NJS 30:4D-17.13; NJAC 8:85-1.8(a). Pre-Admission Screening is also available upon request to a private pay individual for a reasonable fee, whether or not the individual expects to become eligible for the Medicaid program NJS 30:4D-17.14; NJAC 8:85-1.2. Additionally, any resident who has mental illness or mental retardation must also receive such screening or assessment regardless of payment source. NJAC 8:85-1.8(a). 

To pass the Pre-Admission Screen and be found an appropriate nursing facility resident, a Medicaid applicant must require hand-on assistance with three or more activities of daily living (ADLs) or have cognitive impairments that affect his or her ability to perform three or more ADLs independently. NJAC 8:85-2.1(a)(1). The six ADLs are: dressing, bathing toileting, eating, transferring and mobility. 

The office of Community Choice Options (OCCO) employs nurses who perform the Pre-Admission Screening and decide whether the applicant meets the medical requirements of the Medicaid program. OCCO is an office in the Division of Aging Services, which is a part of the State Department of Health and Senior Services. If he or she fails to meet the eligibility criteria on the Pre-Admission Screening, the applicant is disqualified for Medicaid benefits. For individuals applying for Medicaid eligibility at home in order to receive home health aides or adult day care services, there is a telephone Pre-Admission Screening assessment tool that the applicant must satisfy. 

The Pre-Admission Screening assessment tool for hospitals is Form LTC-4, annexed here – Form LTC-4

The Pre-Admission Screening assessment tool for nursing homes is Form LTC-2, annexed here –  Form LTC-2

The Pre-Admission Screening assessment tool for County Welfare Agencies, Boards of Social Services and County Office on Aging/Area Agencies on Aging is Form CP-2, annexed here –  Form CP-2

Physicians referring people through County Welfare Agencies and Board of Social Services, and individuals referred from the community use Form PA-4, annexed here –  Form PA-4

The Pre-Admission Screening assessment tool for services in the community is annexed here – Community Screen

The Pre-Admission Screening assessment tool for services in an assisted living facility is annexed here – AL-6 – Referral for Global Opions for Long-Term Care (GO) Medicaid Waiver

For additional information concerning Medicaid applications and appeals, visit:
http://vanarellilaw.com/medicaid-applications-medicaid-appeals/

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