N.J. Admin. Code § 8:85-1.8

Current through Register Vol. 56, No. 21, November 4, 2024

Section 8:85-1.8 - Pre-Admission Screening (PAS), admission and authorization

(a) Pursuant to 30:4D-17.1 0, a Medicaid-participating NF shall not admit an individual who is financially eligible for Medicaid or who may become financially eligible for Medicaid within 180 days of admission to the NF, or, regardless of payment source, an individual with MI or MR/Related Condition (RC), unless professional staff designated by the Department have completed a Level I PASRR for the individual and the individual is determined clinically eligible for NF placement.

1. An individual who is financially and clinically eligible for Medicaid residing in a Medicaid-participating NF who is transferred to an acute care hospital shall not be subject to PAS prior to returning to the same or another NF.

2. If an individual who is financially and clinically eligible for Medicaid identified as having MI residing in a Medicaid-participating NF is admitted to a psychiatric unit for treatment for less than one year, the individual shall not be subject to PASRR prior to returning to the NF.

3. When an NF resident with MI or MR/RC is transferred to another NF, the admitting NF shall be responsible for ensuring that a copy of the resident's current PASRR determination, MDS (see 8:39-11.2(e) ) and HSDP (N.J.A.C. 8:85 Appendix L, incorporated herein by reference) accompany the transferring resident.

4. If the Level I PASRR required by this subsection is positive, professional staff designated by the Department shall refer the individual to either DDD or DMHS for completion of a Level II evaluation and determination.

(b) The New Jersey Medicaid program shall not pay for NF services provided to a resident paying from private funds who has applied for Medicaid benefits unless professional staff designated by the Department has determined that the resident is clinically eligible to receive NF services through PAS.

1. If a NF has admitted an individual who is financially eligible for Medicaid or who may become financially eligible for Medicaid within 180 days of admission without the professional staff designated by the Department first determining, through PAS, that the individual is clinically eligible for NF services, the effective date of the initial authorization will be the date the PAS is completed. The New Jersey Medicaid program shall not reimburse NFs admitting such individuals without PAS for any care rendered before PAS.

(c) Within two working days of an NF's admission of an individual who is financially eligible for Medicaid, the NF shall submit a completed Notification From Long-Term Care Facility of the Admission or Termination of a Medicaid Patient, also known as an LTC-2 form, provided at N.J.A.C. 8:85 Appendix G, incorporated herein by reference, and available for download at www.state.nj.us/health/ltc/formspub.htm and at http://nj.gov/health/forms/index.shtml, to the OCCO serving the county in which the NF is located.

1. The NF shall obtain from the appropriate CWA a statement of the individual's budgetary information on the Statement of Available Income for Medicaid Payment form, also known as form PA-3L, or form PR-1, provided at Appendix F, incorporated herein by reference.

(d) Professional staff designated by the Department shall conduct PAS by reviewing the individual's medical, nursing and social information and any other supporting data, in order to assess the individual's care needs and determine the appropriate setting for the delivery of needed services. The professional staff designated by the Department shall authorize or deny NF placement based on the results of the standardized assessment performed by professional staff designated by the Department, in accordance with (e) below, that documents the individual's clinical eligibility pursuant to 8:85-2.1 and the feasibility of alternative placement.

1. For each NF applicant with MI or MR whose standardized assessment and PAS results in a determination that the individual is clinically eligible for NF placement, the DMHS or the DDD, as appropriate, will conduct PASRR evaluation and determination, prior to the Department's issuance of a written determination authorizing NF placement.

i. With respect to an individual with MI/RC seeking authorization for NF placement, the individual, or the individual's legal representative, social worker or other entity referring the individual, or with respect to an individual with MI/RC who is already an NF resident who is experiencing a change from the condition described on the resident's MDS, the NF, shall complete the identifying information on the Psychiatric Evaluation form provided at N.J.A.C. 8:85 Appendix I, incorporated herein by reference; shall have the remainder of the evaluation completed by a psychiatrist, physician (doctors of medicine or osteopathy), certified nurse practitioner, certificated pursuant to 45:11-45 et seq., and certified in the advanced practice of psychiatric nursing or mental health or clinical nurse specialist, certificated pursuant to 45:11-45 et seq., and certified in the advanced practice of psychiatric nursing or mental health; and shall send the completed form to the DMHS, which will conduct PASRR based upon the information provided in the Psychiatric Evaluation form.

(1) Individuals having a documented primary diagnosis of dementia including Alzheimer's disease are not subject to a PASRR Level II evaluation by DMHS as a precondition to a determination of Medicaid clinical eligibility for NF admission.

ii. With respect to an individual with MR/RC, the OCCO will forward the Level I screen to the appropriate DDD staff for the completion of the Level II PASRR evaluation and determination.

(1) Individuals with MR/RC and a diagnosis of dementia including Alzheimer's disease are subject to a PASRR Level II evaluation and determination by DDD as a precondition to a determination of Medicaid clinical eligibility for NF admission.

iii. In the case of an individual dually diagnosed with MI and MR/RC, the PASRR Level II evaluation shall be done by DMHS and DDD concurrently.

iv. The DMHS and/or the DDD, as applicable, will each transmit its respective PASRR determination to the OCCO and the OCCO will transmit the PASRR determination to the individual or, if applicable, the individual's legal representative, the appropriate State authority, admitting or referring NF, individual's attending physician and the discharging hospital.

(1) If the PASRR results in a determination that no specialized services are required, the Department shall approve NF placement and shall issue an NF approval letter to the individual or, if applicable, the individual's legal representative, in the form provided at N.J.A.C. 8:85 Appendix M, incorporated herein by reference, and shall enclose with the letter a copy of the PASRR determination.

(A) DDD and/or DMHS, as applicable, shall forward a copy of the PASRR determination to the individual, or the individual's legal representative, the appropriate State authority, admitting or referring NF, the individual's attending physician and the discharging hospital.

(2) If the PASRR results in a determination that the individual requires specialized services for MI or MR/RC, then NF placement is inappropriate and the Department shall issue to the individual or, if applicable, the individual's legal representative and the referring individual a letter denying Medicaid authorization for NF placement in the form provided at N.J.A.C. 8:85 Appendix N, incorporated herein by reference.

(A) DMHS and/or DDD, as applicable, shall forward a copy of the PASRR determination to the individual, or the individual's legal representative, the appropriate State authority, admitting or referring NF, the individual's attending physician and the discharging hospital, and shall assist in finding appropriate placement and/or services for the individual.

v. If PAS results in a determination that the individual is not clinically eligible for NF placement pursuant to the requirements of N.J.A.C. 8:85-2.1, PASRR is not required.

(e) The following procedure is to be used by a referent when seeking Medicaid authorization of NF placement through PAS prior to the admission of individuals who are financially eligible for Medicaid or individuals residing in an NF paying from private funds who may become eligible for Medicaid within 180 days.

1. If the referent is a hospital, the hospital shall identify individuals who are or potentially are at risk for NF placement, including individuals with MI and/or MR/RC who may require PASRR, by consulting the "At-Risk Criteria for Nursing Facility Placement," also known as form LTC-D1, provided at N.J.A.C. 8:85 Appendix J, incorporated herein by reference, and available for download at http://www.state.nj.us/health/forms. The hospital shall refer such individuals to the OCCO for a PAS and, if appropriate, to the CWA for determination of financial eligibility. The hospital should submit to the OCCO the completed Hospital Preadmission Screening Referral form, also known as form LTC-4, provided as N.J.A.C. 8:85 Appendix T, incorporated herein by reference, and available for download at http://www.state.nj.us/health/forms and at www.state.nj.us/health/ltc/formspub.htm, to notify the OCCO for PAS and, if appropriate, the CWA for determination of financial eligibility.

i. Professional staff designated by the Department will conduct PAS using a standardized assessment instrument provided at N.J.A.C. 8:85 Appendix K, incorporated herein by reference, and upon the conclusion of the assessment, shall verbally advise the referent, the individual, and the individual's family member or legal representative as to whether the individual is clinically eligible for NF placement and whether PASRR is required.

(1) If the individual is clinically eligible for NF placement and does not require PASRR Level II evaluation, then upon conclusion of PAS, the professional staff designated by the Department shall provide the referent with a copy of an executed approval letter in the form provided at N.J.A.C. 8:85 Appendix M and a completed HSDP in the form provided at N.J.A.C. 8:85 Appendix L, and the OCCO shall mail the original approval letter to the individual, or, if applicable, the individual's legal representative, and shall send a copy of the approval letter to the CWA.

(2) If the individual is clinically ineligible for NF placement, the OCCO shall mail a letter denying Medicaid authorization for NF placement in the form provided at N.J.A.C. 8:85 Appendix N to the individual or, if applicable, the individual's legal representative and shall mail a copy of the letter to the CWA.

(3) If the individual is clinically eligible for NF placement but PASRR Level II evaluation is required, the professional staff designated by the Department shall provide the individual or the individual's legal representative, the appropriate State authority, admitting or referring NF, individual's attending physician and the discharging hospital, with written notice of the necessity of PASRR in the form provided at N.J.A.C. 8:85 Appendix R, incorporated herein by reference, also known as form LTC-L6a, with respect to individuals with MI, and in the form provided at N.J.A.C. 8:85 Appendix S, incorporated herein by reference, also known as LTC-L7a, with respect to individuals with MR/RC.

(4) Upon conclusion of PASRR, if PASRR Level II evaluation results in a determination that the individual does not require specialized services for MI or MR/RC, then the OCCO shall mail the original approval letter in the form provided at N.J.A.C. 8:85 Appendix M to the individual, or, as appropriate, to the individual's legal representative, the appropriate State authority, admitting or referring NF, individual's attending physician and the discharging hospital, and shall mail a copy of the executed approval letter and a completed HSDP in the form provided at N.J.A.C. 8:85 Appendix L to the referent.

(5) Upon conclusion of PASRR, if PASRR Level II evaluation results in a determination that the individual requires specialized services for MI or MR/RC, then the OCCO shall mail a letter denying Medicaid authorization for NF placement in the form provided at N.J.A.C. 8:85 Appendix N, incorporated herein by reference, to the individual or, as appropriate, the individual's legal representative, and the DMHS or the DDD, as appropriate, will assist in finding appropriate placement and/or services for the individual.

(6) If an individual being transferred from a hospital setting to a NF is or will be eligible for Medicare benefits, the transfer shall, to the extent possible, be made to a Medicare and Medicaid participating NF.

2. If the referent is an NF, the referent shall refer an individual no later than 180 days prior to the individual's anticipated date of Medicaid eligibility by submitting the completed Notification from Long-Term Care Facility of Admission or Termination of a Medicaid Patient form, also known as the LTC-2 form, provided at N.J.A.C. 8:85 Appendix G, incorporated herein by reference, and available for download at www.state.nj.us/health/forms and at www.state.nj.us/health/ltc/formspub.htm, to the OCCO for PAS and by submitting a copy of the form to the CWA for a determination of financial eligibility.

i. Professional staff designated by the Department shall conduct PAS in accordance with the procedure provided in (d) above and by completing the standardized assessment.

ii. When the CWA determines that the individual is financially eligible for Medicaid, the CWA shall forward the LTC-2 form to the OCCO indicating a change in the individual's status from private pay to financially eligible for Medicaid.

3. A person or entity shall refer an individual residing in the community who is seeking admission to a Medicaid-participating NF and who is financially eligible for Medicaid or who may become financially eligible for Medicaid within 180 days of admission to an NF, or an individual with MI or MR/RC, to the OCCO for PAS and, if appropriate, to the CWA for a determination of financial eligibility by submitting to the OCCO a completed Certification of Need for Patient Care in Facility other than Public or Private General Hospital, also known as a PA-4 form, provided at N.J.A.C. 8:85 Appendix H, incorporated herein by reference, and available for download at http://nj.gov/health/forms/index.shtml.

i. Upon receipt by the OCCO of a PA-4 form or a physician statement that substantiates the individual's diagnosis and describes the individual's care needs, professional staff designated by the Department shall conduct PAS in accordance with the procedure provided in (d) above and by completing the standardized assessment.

(1) Upon conclusion of PAS, the professional staff designated by the Department shall verbally advise the individual or, if applicable, the individual's legal representative, as to whether the individual is clinically eligible for NF services, and the OCCO shall mail either the approval letter in the form provided in N.J.A.C. 8:85 Appendix M, or the denial letter in the form provided in N.J.A.C. 8:85 Appendix N, to the individual or, if applicable, the individual's legal representative, and shall send a copy of the letter to the CWA.

ii. For individuals residing in the community with MI, professional staff designated by the Department shall verbally advise the individual or, if applicable, the individual's legal representative, at the conclusion of PAS whether the individual is clinically eligible for NF placement.

(1) If the individual is not clinically eligible for NF placement, the OCCO shall mail an executed denial letter in the form provided at N.J.A.C. 8:85 Appendix N to the individual or, if applicable, the individual's legal representative.

(2) If the individual is clinically eligible for NF placement, the professional staff designated by the Department will provide the individual or, if applicable, the individual's legal representative, with an executed form LTC-L6a advising the individual or representative, of the need to have the Psychiatric Evaluation form provided at Appendix I completed by a psychiatrist, physician (doctors of medicine or osteopathy), certified nurse practitioner certificated pursuant to 45:11-45 et seq., and certified in the advanced practice of psychiatric nursing or mental health or clinical nurse specialist certificated pursuant to 45:11-45 et seq., and certified in the advanced practice of psychiatric nursing or mental health pursuant to 45:11-45 et seq. and the need to forward the form to the DMHS.

(3) If the PASRR Level II determination by the DMHS results in a determination that the individual requires specialized services for MI, then NF placement is not appropriate and the OCCO shall mail an executed denial letter in the form provided at N.J.A.C. 8:85 Appendix N and a copy of the PASRR determination to the individual or, if applicable, the individual's legal representative, and the DMHS shall assist the individual in securing appropriate placement and/or services.

(4) If the PASRR Level II evaluation by the DMHS results in a determination that the individual does not require specialized services for MI, the OCCO shall mail the approval letter in the form provided in N.J.A.C. 8:85 Appendix M and a copy of the PASRR determination to the individual or, if applicable, the individual's legal representative, and shall transmit a copy of the approval letter to the CWA.

iii. For individuals residing in the community with MR/RC, professional staff designated by the Department shall verbally advise the individual or, if applicable, the individual's legal representative, at the conclusion of PAS whether the individual is clinically eligible for NF placement.

(1) If the individual is not clinically eligible for NF placement, the OCCO shall mail, an executed denial letter in the form provided at N.J.A.C. 8:85 Appendix N to the individual, or if applicable, the individual's legal representative.

(2) If the individual is clinically eligible for NF placement, professional staff designated by the Department shall provide the individual or the individual's legal representative, with an executed form LTC-L7a advising the individual or representative, of the need for the DDD to conduct PASRR.

(3) If PASRR by the DDD results in a determination that the individual requires specialized services for MR/RC, then NF placement is not appropriate and the OCCO shall mail an executed denial letter in the form provided at N.J.A.C. 8:85 Appendix N and a copy of the PASRR determination to the individual or, if applicable, the individual's legal representative and the DDD shall assist the individual in securing appropriate placement and/or services.

(4) If PASRR by the DDD results in a determination that the individual does not require specialized services for MR/RC, the OCCO shall mail the approval letter in the form provided in N.J.A.C. 8:85 Appendix M and a copy of the PASRR determination to the individual or, if applicable, the individual's legal representative, and shall transmit a copy of the approval letter to the CWA.

iv. In the case of an individual dually diagnosed with MI and MR/RC, the conduct of PASRR by the DMHS shall precede the conduct of PASRR by the DDD.

(f) Authorization of out-of-State NF placement is subject to the following additional conditions:

1. Prior authorization shall be obtained from the Department for out-of-State NF services and shall be considered only when a required long-term care service is not available in New Jersey.

2. The out-of-State facility shall be licensed under the laws of that state as a NF or SCNF or equivalent entity, howsoever labeled by that state, and the rate of reimbursement shall not exceed that authorized by the Medicaid program of the state in which the facility is located, or the reimbursement rate authorized by the New Jersey Medicaid Program, whichever is lower.

3. Requests for prior authorization for out-of-State placement shall be accompanied by sufficient evidence that the service is medically necessary and not available in New Jersey. The Department will review the records provided to determine the need for long-term care services and to determine the appropriateness of placing the beneficiary in a NF outside of New Jersey. The request must be submitted to: Office of Community Choice Options

Division of Aging and Community Services

Department of Health and Senior Services

PO Box 807

Trenton, NJ 08625-0807

4. Prior to submitting a request for out-of-State placement, the beneficiary shall comply with the requirements of PAS as specified in this subchapter.

(g) The procedure for Department authorization of Medicaid reimbursement for NF continued stay or alternative care is as follows:

1. The professional staff designated by the Department shall periodically assess Medicaid beneficiaries to review the NF's assessments, patient classifications, and case mix reporting, and may recommend continuation of NF stay or, if appropriate, deny continued NF stay and shall recommend discharge to an alternative to NF stay.

2. Professional staff designated by the Department shall provide care management on an ongoing basis to Medicaid beneficiaries following placement in a NF.

3. Professional staff designated by the Department shall examine resident records for proof of continued vigilance and effort by the NF to utilize alternative means of care for all residents.

i. Beneficiaries designated as Track II (short-term) shall be monitored closely by the Department to assure active participation by the NF in the discharge planning process.

(h) If a NF resident with MI or MR/RC shows a significant change in condition as defined by the MDS, the NF shall initiate treatment to meet immediate needs. The NF shall arrange for the conduct and completion of a comprehensive reassessment by the end of the 14th day of the documented change in condition. If the reassessment results in a finding that a significant change in the resident's condition has occurred, the NF shall revise the resident's care plan based on that reassessment within seven days of the completion of the reassessment, shall make a clinical judgment, based on the clinical data, as to whether or not PASRR by DMHS or DDD is needed, and if so, shall notify the DMHS and/or the DDD, as appropriate, of the need for PASRR.

(i) Professional staff designated by the Department, after considering and rejecting all possible means of alternative care, shall approve conventional NF placement for Medicaid beneficiaries residing in a NF approved for a SCNF rate of reimbursement who continue to require NF level of nursing care, but who no longer require SCNF level of nursing care.

(j) The NF shall notify the OCCO, via the LTC-2 form, of the termination of NF services due to the beneficiary's:

1. Death while either in the NF or hospitalized;

2. Discharge to home or other community living arrangement;

3. Transfer to another NF; or

4. Ineligibility determination.

N.J. Admin. Code § 8:85-1.8

New Rule, R.2005 d.389, effective 1/17/2006.
See: 36 N.J.R. 4700(a), 37 N.J.R. 1185(a), 38 N.J.R. 674(a).
Former N.J.A.C. 10:63-1.8, Admission, transfer and readmission; general, repealed.
Amended by R.2011 d.121, effective 4/18/2011.
See: 42 N.J.R. 1793(a), 43 N.J.R. 961(c).
Section was "Pre-Admission Screening (PAS), admission, and authorization". Rewrote the introductory paragraph of (a); in (a)3, substituted "an" for "a" and "MR/RC" for "MR", deleted a comma preceding "and HSDP", and inserted "N.J.A.C. 8:85"; added (a)4; in the introductory paragraph of (c), substituted "an" for "a" and "OCCO" for "LTCFO", and inserted "N.J.A.C. 8:85"; rewrote (d) and (e); in (h), substituted "MR/RC" for "MR"; in the introductory paragraph of (j), substituted "OCCO" for "LTCFO"; and recodified former (j)i through (j)iv as (j)1 through (j)4.