Chapter 514 - Nursing Facility Services - DHHR - State of West ...

Is developed under and supervised by a physician in conjunction with an IDT which includesqualified mental health professionals;Prescribes specific therapies and activities for the treatment of persons experiencing anacute episode of a major mental illness which necessitates supervision by trained mentalhealth professionals; andIs directed toward reducing the individual’s acute psychotic symptoms that adversely affectthe person’s ability to perform their activities of daily living. The long term goal of thespecific therapies is to improve the individual’s level of independent functioning and toachieve a functional level that permits reduction in the intensity of mental health services atthe earliest possible time.These services may only be provided in an acute psychiatric facility. If the resident orresponsible party refuse this service, if it is recommended during the Level II review, theindividual cannot be admitted to the nursing facility or continue to reside in the facility.514.6.9 Fair Hearing ProcessA Pre-admission Screening (PAS) form will be completed to determine Medicaid medicaleligibility for nursing facility placement. If the PAS is determined not to meet Medicaid medicaleligibility after being reviewed by BMS’ UMC, the member or their responsible party has theright to request a Fair Hearing. During the appeal, the resident may chose to remain at thefacility. If the resident is a Medicaid member at the time of appeal, the facility will receivecontinued payment during the appeal process. . After the hearing, the Hearing Officer will issuethe decision, in writing, to BMS, the nursing facility and member/responsible party. This letter,from the Hearing Officer, will have the effective date of the decision. If the decision is to upholdthe denial for Medicaid Medical Eligibility, the facility will have 35 days of continued Medicaidpayment, in order to account for mailing time.At the beginning of the 35-day discharge period, the facility will issue a 30-day discharge letterto the resident so that the facility will be able to conduct a safe and orderly discharge whilereceiving continued payment, in accordance with Code of Federal Regulation 42 CFR Ch. IV,483.12 (7).514.6.10 Contribution to the Cost of CareAs a part of the financial eligibility determination for the Medicaid nursing facilities benefit, theDHHR calculates the dollar amount the individual must contribute to the cost of care everymonth. The monthly Medicaid payment to the nursing facility will be reduced by the dollaramount of the contribution to the cost of care (resource).The administrator or designee is responsible for collecting the monthly contribution to the cost ofcare. If the administrator or designee is unable to collect the money for any reason, that dollaramount may not be charged to the Medicaid program in any manner.Department of Health and Human Resources Chapter 514: Nursing Facility Services Page 33January 1, 2013DISCLAIMER: This manual does not address all the complexities of Medicaid policies and procedures,and must be supplemented with all State and Federal Laws and Regulations.