5160-3-14.
Process and timeframes for a level of care determination for nursing facility-based level of care programs
| (A) |
This
rule describes the processes and timeframes for a level of care
determination, as defined in rule 5101:3-3-05 of the Administrative
Code, for a nursing facility (NF)-based level of care program, as
defined in rule 5101:3-3-05 of the Administrative Code.
| (1) |
The
processes described in this rule shall not be used for a
determination for an ICF-MR-based level of care, as defined in rule
5101:3-3-05 of the Administrative Code. |
| (2) |
A
level of care determination may occur face-to-face or by a desk
review, as defined in rule 5101:3-3-05 of the Administrative Code,
and is one component of medicaid eligibility in order to:
| (a) |
Authorize medicaid payment to a NF; or |
| (b) |
Approve medicaid payment of a NF-based home and community-based
services (HCBS) waiver or other NF-based level of care program. |
|
| (3) |
An individual who is seeking a NF admission
is subject to both a preadmission screening and resident review
(PASRR) process, as described in rules 5101:3-3-14, 5101:3-3-15.1,
5101:3-3- 15.2, 5122-21-03, and 5123:2-14-01 of the Administrative
Code, and a level of care determination process.
| (a) |
The
preadmission screening process must be completed before a level of
care determination or a level of care validation can be issued. |
| (b) |
In order for the Ohio department of job and
family services (ODJFS) to authorize payment to a NF, the individual
must have received a non-adverse PASRR determination and subsequent
NF-based level of care determination.
| (i) |
ODJFS
may authorize payment to the NF effective on the date of the PASRR
determination. |
| (ii) |
The
level of care effective date cannot precede the date that the PASRR
requirements were met. |
| (iii) |
If a
NF receives medicaid payment from ODJFS for an individual who does
not have a NF-based level of care, the NF is subject to the claim
adjustment for overpayments process described in rule 5101:3-1-19 of
the Administrative Code. |
|
|
|
| (B) |
Level of care request.
| (1) |
In
order for ODJFS or its designee (hereafter referred to as ODJFS) to
make a level of care determination, ODJFS must receive a complete
level of care request. A level of care request is considered complete
when all necessary data elements are included and completed on the
JFS 03697, "Level of Care Assessment" (rev. 4/2003) or alternative
form, as defined in rule 5101:3-3-05 of the Administrative Code, and
any necessary supporting documentation is submitted with the JFS
03697 or alternative form, as described in paragraphs (B)(2) to
(B)(4) of this rule. |
| (2) |
Necessary data elements on the JFS 03697 or alternative form:
| (a) |
Individual's legal name; |
| (b) |
Individual's medicaid case number, or a pending medicaid case
number; |
| (c) |
Date of original admission to the facility,
if applicable; |
| (d) |
Individual's current address, including
county of residence; |
| (e) |
Individual's current diagnoses; |
| (f) |
Date
of onset for each diagnosis, if available; |
| (g) |
Individual's medications, treatments, and required medical
services; |
| (h) |
A description of the individual's activities
of daily living and instrumental activities of daily living; |
| (i) |
A description of the individual's current
mental and behavioral status; and |
| (j) |
Type
of service setting requested. |
|
| (3) |
Physician certification on the JFS 03697 or alternative form.
| (a) |
A
physician certification means a signature from a physician, as
defined in rule 5101:3-3-05 of the Administrative Code, and date on
the JFS 03697 or alternative form. |
| (b) |
A
physician certification must be obtained within thirty calendar days
of submission of the JFS 03697 or alternative form. |
| (c) |
Exceptions to the physician certification:
| (i) |
When
an individual resides in the community and ODJFS determines that the
individual's health and welfare is at risk and that it is not
possible for the submitter of the JFS 03697 or alternative form to
obtain a physician signature and date at the time of the submission
of the JFS 03697 or alternative form, a verbal physician
certification is acceptable. |
| (ii) |
ODJFS
must obtain a physician certification within thirty days of the
verbal physician certification. |
|
|
| (4) |
Necessary supporting documentation with the
JFS 03697 or alternative form when the individual is subject to a
preadmission screening process:
| (a) |
A copy
of the JFS 03622, "Preadmission Screening/Resident Review (PAS/RR)
Identification Screen" (rev. 11/2010) and JFS 07000, "Hospital
Exemption from Preadmission Screening Notification" (rev. 11/2010),
as applicable, in accordance with rules 5101:3-3-15.1 and 5101:3-3-
15.2 of the Administrative Code; and |
| (b) |
Any
preadmission screening results and assessment forms. |
|
|
| (C) |
Process when ODJFS receives a complete level
of care request.
| (1) |
When ODJFS determines that a level of care
request is complete, ODJFS shall:
| (a) |
Issue
a level of care determination. |
| (b) |
Inform
the individual, and/or the sponsor and the authorized representative,
as applicable, about the individual's PASRR results. |
| (c) |
Notify
the individual, and/or the sponsor and the authorized representative,
as applicable, as defined in rule 5101:3-3-05 of the Administrative
Code, of the level of care determination. |
| (d) |
When
there is an adverse level of care determination, inform the
individual, the sponsor, and the authorized representative, as
applicable, about the individual's hearing rights in accordance with
division 5101:6 of the Administrative Code. |
|
| (2) |
In accordance with rules 5101:1-38-01 and
5101:1-39-23 of the Administrative Code, the county department of job
and family services (CDJFS) shall determine medicaid eligibility and
issue proper notice and hearing rights to the individual. |
|
| (D) |
Process when ODJFS receives an incomplete
level of care request.
| (1) |
When ODJFS determines that a level of care
request is not complete, ODJFS shall:
| (a) |
Notify
the submitter that a level of care determination cannot be issued due
to an incomplete JFS 03697 or alternative form. |
| (b) |
Specify the necessary information the submitter must provide on or
with the JFS 03697 or alternative form. |
| (c) |
Notify
the submitter that the level of care request will be denied if the
submitter does not submit the necessary information to ODJFS within
fourteen calendar days.
| (i) |
When the submitter provides a complete level
of care request to ODJFS within the fourteen calendar day timeframe,
ODJFS shall perform the steps described in paragraph (C) of this
rule. |
| (ii) |
When the submitter does not provide a
complete level of care request to ODJFS within the fourteen calendar
day timeframe, ODJFS may deny the level of care request and document
the denial in the individual's electronic record maintained by
ODJFS. |
|
|
| (2) |
In
accordance with rules 5101:1-38-01 and 5101:1-39-23 of the
Administrative Code, the CDJFS shall determine medicaid eligibility
and issue proper notice and hearing rights to the individual. |
|
| (E) |
Desk review level of care
determination.
| (1) |
A desk review level of care determination is
required within one business day from the date of receipt of a
complete level of care request when:
| (a) |
ODJFS
determines that an individual is seeking admission or re-admission to
a NF from an acute care hospital or hospital emergency room. |
| (b) |
A CDJFS requests a level of care
determination for an individual who is receiving adult protective
services, as defined in rule
5101:2-20-01
of the Administrative Code, and the CDJFS submits a JFS 03697 or
alternative form at the time of the level of care request. |
|
| (2) |
A desk review level of care determination is
required within five calendar days from the date of receipt of a
complete level of care request when:
| (a) |
ODJFS
determines that an individual who resides in a NF is requesting to
change from a non-medicaid payor to medicaid payment for the
individual's continued NF stay. |
| (b) |
ODJFS
determines that an individual who resides in a NF is requesting to
change from medicaid managed care to medicaid fee-for-service as
payment for the individual's continued NF stay. |
| (c) |
ODJFS
determines that an individual is transferring from one NF to another
NF. |
|
|
| (F) |
Face-to-face level of care determination.
| (1) |
A
face-to-face level of care determination is required within ten
calendar days from the date of receipt of a complete level of care
request when:
| (a) |
An individual or the authorized
representative of an individual requests a face-to-face level of care
determination. |
| (b) |
ODJFS makes an adverse level of care
determination, as defined in rule 5101:3-3-05 of the Administrative
Code, during a desk review level of care determination. |
| (c) |
ODJFS determines that the information needed
to make a level of care determination through a desk review is
inconsistent. |
| (d) |
An individual resides in the community and
ODJFS verifies that the individual does not have a current NF-based
level of care. |
| (e) |
ODJFS determines that an individual has a
pending disenrollment from a NF-based HCBS waiver due to the
individual no longer having a NF-based level of care. |
|
| (2) |
A face-to-face level of care determination
is required within two business days from the date of a level of care
request from a CDJFS for an individual who is receiving adult
protective services when the CDJFS does not submit a JFS 03697 or
alternative form at the time of the level of care request. |
|
| (G) |
Delayed face-to-face visit.
| (1) |
A
delayed face-to-face visit, as defined in rule 5101:3-3-05 of the
Administrative Code, is required within ninety calendar days after
ODJFS conducts a desk review level of care determination for an
individual as described in paragraphs (E)(1)(a), (E)(1)(b), and
(E)(2)(a) of this rule. |
| (2) |
The
following are exceptions to the delayed face-to-face visit:
| (a) |
An
individual as described in paragraphs (E)(2)(b) and (E)(2)(c) of this
rule. |
| (b) |
An individual who declines a delayed
face-to-face visit. |
| (c) |
An
individual who has had a long-term care consultation, in accordance
with Chapter 173-43 of the Administrative Code, since the
individual's NF admission. |
| (d) |
An
individual who has had an in-person resident review, in accordance
with Chapter 5101:3-3 of the Administrative Code, since the
individual's NF admission. |
| (e) |
An
individual who is receiving care under a medicaid care management
system that utilizes a care management, case management, or care
coordination model, including but not limited to case management
services provided through an HCBS waiver. |
|
|
| (H) |
Level of care validation. ODJFS may conduct a level of
care validation, as defined in rule 5101:3-3-05 of the Administrative
Code, in lieu of a face-to-face level of care determination within
one business day from the date of a level of care request for:
| (1) |
An individual who is enrolled on a NF-based HCBS
waiver and is seeking admission to a NF. |
| (2) |
An
individual who is a NF resident and is seeking readmission to the
same NF after a hospitalization. Replaces: 5101:3-3-15
|
|
Cite as Ohio Admin. Code 5160-3-14
History. Effective:
03/19/2012
R.C.
119.032 review dates:
03/01/2017
Promulgated Under:
119.03
Statutory Authority:
5111.02
Rule Amplifies:
5111.01,
5111.02 ,
5111.204,
5111.205
Prior Effective Dates: 4/7/77, 10/14/77, 7/1/80, 8/1/84,
1/17/92 (Emer.), 4/16/92, 10/1/93 (Emer.), 12/31/93, 7/1/08