John Elias Baldacci Governor

STATE OF MAINE DEPARTMENT OF HUMAN SERVICES BUREAU OF ELDER AND ADULT SERVICES 442 CIVIC CENTER DRIVE 11 STATE HOUSE STATION AUGUSTA, MAINE 04333-0011

To:	Interested Parties
From:	Christine Gianopoulos, Director
Date:	January 26, 2004
Subject:	MaineCare Nursing Facility Eligibility Assessment Procedures

 

Ø      MaineCare residents now receive a two-year extended eligibility date at the first re-assessment after admission, unless the assessor anticipates the resident's condition may change.

 

Ø      MaineCare-eligible residents returning from the hospital no longer require an assessment, unless their bed-hold has expired.

 

Ø      Residents with a 90-day medical eligibility will continue to have a face-to-face assessment because those are situations where the resident’s condition often has improved. Based on all relevant information, Goold may grant an extended NF classification.  Please pay close attention to the paperwork received regarding subsequent reassessment due dates.

 

Ø      Extended Nursing Facility Classifications have been granted since 2002. There are no plans to conduct face-to-face assessments on these consumers

 

Here are some examples where the Department may revise the assessment outcome, rather than complete a face-to-face assessment:

 

Reassessment of Current NF Resident: Please continue to submit these requests to Goold.  Goold will review the resident’s assessment history, medical, and financial eligibility. Rather than completing a face-to-face assessment, Goold may revise the assessment request to authorize an extended NF classification and send the revised assessment outcome and the letters to the NF, the consumer, and family members, as appropriate. To avoid any gaps in payment, please submit the reassessment request for these residents at least five days prior to the reassessment due date.

 

Extended Nursing Facility Classifications: Extended classifications began in 2002. Since the average length of a MaineCare nursing home stay is 21 months, we are not sure how many of these residents still are in facilities. There are no plans to conduct face-to-face assessments on these consumers. For those that do come due this year, we will grant another extension.

 

To avoid any gaps in payment, please submit the reassessment request for these residents at least five days prior to the reassessment due date. Goold will review the individual consumer information to assure that MaineCare financial eligibility remains active, and then revise and extend the NF classification date forward another two years. Goold will send a copy of the revised MED XX and the corroborating letters to the consumer and NF.  Goold will forward the revised outcome to BEAS for data entry into Welfre to assure claims payment.

 

MaineCare NF Resident Returning from Hospital: No longer requires an assessment, unless their bed-hold has expired.

 

Medicare to MaineCare (Medicaid): When a MaineCare NF resident returns from the hospital under Medicare, a face-to-face assessment is not needed at the end of the SNF benefit, unless their reassessment date came due during their SNF stay, or they are within the first 90 days of NF eligibility. In these cases, request a reassessment.  After review of the member’s prior assessments, Goold will request the Department to reinstate the prior reassessment date. Any reassessment date that existed prior to the admission to the hospital will remain as the reassessment date. BEAS will fax to the NF the reinstated reassessment date so you have a copy for your records. It is essential that the required assessment requests be submitted to Goold to avoid any gaps in payment.  

 

Please note: Medicare SNF residents applying for MaineCare still require a face-to-face assessment.

 

Bed Holds: Please continue to send the transfer forms to the Department to request bed holds on admission to the hospital, and end bed holds on the return to the NF from the hospital. If the Department does not receive the transfer form, the bed-hold screen date will lapse and payment will cease until the medical eligibility is reopened. 

 

These changes in re-assessment procedures do not change the NF responsibility to know their payment source and to request timely reassessments as required by policy. Section 67.05-4 state “the NF must submit a complete referral form to request a reassessment at least five (5) calendar days prior to the end date of the resident’s current approved classification …..”.

 

Please contact Mollie Baldwin at 287-9200, or Mollie.Baldwin@maine.gov with any questions or concerns.