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

It is the responsibility of the nursing facility to notify the local WV DHHR office when a Medicaidmember is admitted to the facility and when a member discharges from the facility in order forthe facility and member to receive the appropriate benefit.514.6.11 Admission PoliciesA nursing facility must not require a resident, a potential resident or his/her representative towaive rights to Medicaid benefits. A governing body or designee of a nursing facility must notcharge, solicit, accept or receive any gifts, money, donations or other consideration as aprecondition of admission, expedited admission or continued stay in the facility for any personeligible for Medicaid.The WVDHHR has established a process of evaluation to determine eligibility for long term careservices under the Medicaid Program. The evaluation is made on each member frominformation supplied by a physician, member or family/representative, health care facility and/oreligibility worker in the local Department of Health and Human Resources office. Thisdetermination for the Medicaid benefit for nursing facility is based on both medical and financialcriteria. BMS or its designee is responsible for the medical necessity determination and the WVBureau for Children and Families is responsible for the financial determination. Theadministrator or designee is responsible for verifying continued eligibility for residents.Medical eligibility must be established prior to payment for services. Medicaid will not pay forany services prior to the resident qualifying for services both medically and financially.The local WVDHHR office is responsible for notifying the individual/representative, the Bureauand the nursing facility of the date Medicaid eligibility begins.514.6.12 Physician Recertification of Continued StayRecertification of the continuing need for nursing facility care must be documented in theresident’s medical record by the physician at 60days, 180days, then annually after the initialcertification. The administrator/designee must obtain recertification documentation from thephysician for each nursing facility resident for whom payment is requested under the Medicaidprogram.514.7 MANDATORY SERVICESThe following are mandatory services and are included in the per diem rate514.7.1 In-Services Education ProgramA written orientation program must be received by all new employees. The orientation programmust be maintained at the facility. This program must include:A review of all policies for the nursing facility that pertain to the employee’s position;An ongoing, in-service education plan for the development and improvement of skillsDepartment of Health and Human Resources Chapter 514: Nursing Facility Services Page 34January 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.