8114 CARE Assessment Process and Eligibility - All individuals applying for admission to a nursing facility, either as private pay or under medical assistance must have a needs assessment completed to determine if a nursing facility level of care is appropriate. The assessment will also determine if the individual has mental illness or mental retardation (a or related condition) and is in need of specialized services. KDOA is responsible for management of the assessment process. The current screening instrument, the Client Assessment, Referral and Evaluation (CARE) is completed by the Area Agencies on Aging (AAA) or designees. The CARE process also incorporates federal Pre-admission Screening and Resident Review (PASRR) requirements. The CARE includes a Level I assessment, which is completed for all persons. A Level II evaluation is completed if mental illness or mental retardation is indicated through the Level I.
For most persons seeking medical assistance in a nursing facility or nursing facility for mental health, a level of care (LOC) threshold must be met. The threshold, determined by KDOA, is commonly referred to as functional eligibility. The need for a functional eligibility determination must be evaluated for all individuals requesting medical assistance reimbursement of facility expenses. The CARE is the primary instrument used for making a functional eligibility determination, along with the Uniform Assessment Instrument (UAI) and the Multiple Data Set (MDS) in limited situations. LOC information is obtained through KDOA using the KDOA CARE inquiry system or the ES-3164.
Individuals who are determined to be exempt from a CARE assessment, as described in 8114.1 and 8114.2, do not require a LOC determination, nor are they negatively impacted by a LOC score below the threshold.
8114.1 CARE Exceptions - Unless delayed or not required as per Section 2.1 of the KDOA Field Services Manual at http://www.aging.ks.gov/Manuals/FSM/FSMDisclaim.pdf payment to the facility shall not be approved until the CARE is completed (or the PASRR requirements have been otherwise satisfied as per KDOA) and the individual has been found to meet LOC requirements.
A CARE assessment may be delayed if the individual is admitted under a provisional or emergency admission as defined by KDOA. Emergency admissions are made in specified situations, such as an APS placement, to allow the individual to obtain immediate care. Provisional admissions are made for a specified period of time, generally 7 to 30 days, as determined by KDOA. If the individual is otherwise eligible, payment shall be made during the provisional stay. However, persons seeking reimbursement for services following the expiration of the provisional or emergency period must have a CARE completed and meet level of care. Payment shall terminate following the stay if the CARE is not completed, but may be reinstated when the CARE is completed.
Example 1: A 7 day emergency admission is made for an individual on 06-01-04. A CARE assessment is subsequently completed on 06-14-04 and the individual is found in need of care. Payment may be approved for the first 7 days of the stay through the emergency admittance policy. However, continued payments cannot resume until 06-14-04, when the required follow up CARE was completed. There is no Medicaid reimbursement for payment between 06-08-04 and 06-13-04.
Example 2: Individual is admitted under a 30 day provisional on 07/01. On 07/20 the recipient is still at the facility so a LOC score is requested. Verification of the CARE/LOC is received on 07/27 stating client meets the LOC. Payment now continues beyond day 30 because the CARE has been complete and LOC has been met.
For situations not exempt or delayed from CARE, no reimbursement for NF care will be made prior to the completion of the CARE and any necessary Level II screen. If a CARE is completed and the client meets the level of care, Medicaid payment may be approved beginning with the date the CARE assessment was completed. When NF reimbursement is denied for an individual who is otherwise eligible for reimbursement solely because of the delayed CARE, the individual is not responsible for any NF costs during the period of delay. These costs are assumed by the nursing facility.
8114.2 Level of Care Threshold - Verification that the beneficiary has met necessary level of care is required. For the majority of individuals, KDOA will compute a Level of Care score and document the determination on the ES-3164. This will be completed within 10 working days of receiving the request for the determination. However, for persons referred for a Level II evaluation, no LOC score will be computed. Appropriateness of placement is determined by the Level II evaluation, which override, any Level I score. The Level I score will not be communicated if a Level II has been completed. A Level II evaluation may find the individual is approved for a limited stay only. In these situations, payment is approved for the duration of the limited stay only. Medicaid reimbursement terminates at the end of the period unless a subsequent screen provides for extended payment. A new ES-3164 must be sent to the KDOA Coordinator to determine if a new assessment has been completed. The request is initiated 10 days prior to the expiration of the limited stay.
Persons with a Level II approval may be served in an NF or NF MH. However, a Level II evaluation must be completed indicating a need for MH level of care prior to approval for an NF MH placement. Persons without an appropriate Level II finding are not eligible in an NF MH.
The following persons are exempt from a LOC determination:
Provisional Admissions - Persons entering an NF for a stay expected to be 30 days or less due to CARE exception listed in the KDOA FSM section noted above are also exempt from the LOC threshold requirement. A physicians statement documenting the anticipated length of stay is on file with the facility and must be included with the MS-2126. For these situations only, failure to meet the LOC threshold or failure to receive a CARE does not impact eligibility for reimbursement of services. However, coverage beyond day 30 cannot be approved unless the LOC threshold is met.
Persons exempt from a CARE because of previous residence in an NF are also exempt from an LOC determination unless the previous facility was located out of state or an LOC score has not previously been obtained.
Emergency Admissions - The CARE assessment is delayed for admitted to an NF based on an emergency listed in the KDOA FSM section noted above. KDOA will report any emergency admission through the CARE Inquiry system or the ES-3164. Persons remaining in the facility beyond the length of the emergency admission must have a completed CARE for payment to continue. Failure to ultimately obtain the CARE does not impact payment eligibility for the emergency admission period. This is true even if the individual does not meet LOC requirements.
If the client was assessed as appropriate for NF Level of CARE, the client may choose to receive NF care, HCBS or PACE (if available). If the individual chooses NF placements, financial eligibility shall be determined using procedures outlined in 8172.
If an individual residing in an NF does not meet the necessary criteria because a current CARE has not been completed or level of care is not met, financial eligibility is determined according to the procedures outlined in 8171.