Medicaid Eligibility for Nursing Home Care Determination
PDF Version of
BQA 06-014 (PDF, 41 KB)
DATE: June 27, 2006 DDES-BQA-06-014
TO: Nursing Homes NH 10
FROM: Sinikka Santala, Division Administrator, Division of
Disability and Elder Services (DDES)
Mark Moody, Division Administrator, Division of Health Care Financing (DHCF)
Purpose of Memo:
The purpose of this memo is to advise nursing homes of an important
change in how Wisconsin Medicaid Program eligible residents will be
determined entitled to nursing home care. This change is effective July 1,
2006. Beginning July 1, 2006, nursing home residents will no longer be
assigned a specific nursing home Level of Care by Bureau of Quality
Assurance (BQA) nurses. For Title 19 Medicaid residents, an MDS based
automated algorithm will determine whether or not a resident meets
statutory eligibility requirements for nursing home care. The MDS
algorithm determination, either eligible or not eligible, will be reported
to the nursing home. Unlike the past BQA Level of Care determination
process, the new automated system will not be used to determine a resident
specific facility Medicaid payment.
This BQA Numbered Memo is an overall description of the impending
changes to the Medicaid eligibility for nursing home care determination
process. DHCF will provide Medicaid operations information in a Medicaid
Update release later this summer. In addition, a forthcoming BQA Numbered
Memo will address the process to follow regarding documentation necessary
for compliance with the statutory minimum staffing requirements according
to Levels of Care.
For the most part, nursing homes will experience very little change in
the request for determination processing steps. Most of the processing
steps changes will occur within DHS and EDS. Actually, nursing homes will
be relieved of significant paperwork burden as facilities will no longer
be required to submit Level of Care supporting documentation with most of
their eligibility for nursing home care determination requests.
By statute, nursing home residents enrolled in the Medicaid program
must meet certain nursing home care eligibility requirements.
Historically, BQA has established and annually verified a specific nursing
home Level of Care for each Medicaid resident. This information has been
conveyed to the Medicaid fiscal agent, EDS, for payment purposes. Every
nursing home has had a separate payment rate for each nursing home care
level. Nursing homes billed EDS according to the individual resident's
assigned BQA Level of Care each month to receive payment.
The Department of Health and Family Services (DHS) is replacing the
BQA nurse determined Level of Care system with a more consistent and
efficient system developed by Ann Pooler, RN, PhD, and Marianne Missfeldt,
RN, former lead BQA nursing home Level of Care trainer. This new system is
an MDS based automated method which will be used to verify eligibility for
nursing home care effective July 1, 2006, on a go forward basis. (Note:
Separate correspondence from DHCF will also notify facilities of the
upcoming changes to the Medicaid payment system based on a RUGS MDS
Determinations for Existing Residents on June 30, 2006:
For nursing home residents with a BQA nurse determined Level of Care
for days of care provided on or before June 30, 2006, the Level of Care
will be considered verification that the resident remains eligible for
Medicaid funded nursing home care until the resident's next full MDS is
completed. At that time, the resident's continued eligibility for nursing
home care will be determined by the MDS based computer algorithm.
Therefore, over the course of the following 12 months, all existing
Medicaid residents in the facility on June 30, 2006 will have had their
continued eligibility for nursing home care determined by the algorithm.
Determinations for New Medicaid Residents and Any Subsequent Full
Assessment for Existing Medicaid Residents Including Change of Condition
Beginning July 1, 2006:
- For residents who become new Medicaid beneficiaries on or after July
1, 2006, nursing homes will continue to contact their BQA Regional
Office to request a determination for nursing home eligibility using
the current form, DDE-2256. For residents with a MDS in the system or
for whom a MDS will be coming into the system, only the request form
is required. Supporting documentation will no longer be required. BQA
will convey the necessary request information to EDS. EDS will run the
MDS algorithm for each request to verify the resident meets Medicaid
eligibility for nursing home care statutory requirements. EDS will
notify the nursing home of the resident's eligibility for nursing home
care determination. (This process will be in effect from July 1
through September 30, 2006. Beginning October 1, 2006, nursing homes
will submit requests directly to EDS using an EDS form that will
replace the DHS form DDE-2256.) EDS will notify the facility of the
residents determined eligible in its monthly Nursing Home
Authorization Report, #HMKR449Q, as is the current practice.
- EDS will automatically run the MDS algorithm for existing Medicaid
residents with a MDS in the system who require a new full MDS,
including those who experience a significant Change of Condition per
current RAI requirements (TL). The algorithm will determine if the
resident continues to meet Medicaid statutory requirements for nursing
home care. EDS will notify the facility of the residents determined to
continue to be eligible in its monthly Nursing Home Authorization
Report, #HMKR449Q, as is the current practice.
"Not Eligible for Nursing Home Care" Denial Review:
If the MDS algorithm run by EDS results in a "not eligible for
nursing home care" determination for a resident, the determination
will be immediately referred to an EDS nurse for review. The EDS review
nurse will consult with the facility's MDS Coordinator to assure all
needed information has been submitted and the MDS data has been entered
correctly; and to determine if the resident's current condition is
accurately represented on the most recent full MDS assessment. The nursing
home will have the opportunity to submit additional documentation that the
resident's current condition meets Medicaid requirements for nursing home
care eligibility. If the EDS nurse confirms the resident is not eligible
for nursing home care, a BQA nurse will conduct a final review of the
denial. If the BQA nurse also determines that the resident does not meet
eligibility requirements for nursing home care, EDS will immediately
notify the resident and facility of the final denial determination by
letter in the US Mail.
When the final determination is not eligible, the denied resident may
choose to exercise his/her appeal rights under state law. Denied residents
will be notified of their appeal rights. Current Medicaid residents who
are denied continued eligibility for nursing home care and file an appeal
of the denial will continue to be funded by the Medicaid program during
the appeal process.
Also, when the "not eligible" determination is final, BQA
will notify the DDES/Bureau of Long Term Support. Bureau staff will notify
and work with the denied resident's county Human Services Department to
assist the resident with relocation.
No MDS Due to Short Stay:
The eligibility for nursing home care determination algorithm requires
a full MDS, which may not be available for certain residents due to short
stay. In such instances, the Medicaid eligibility for nursing home care
determination will be made by the EDS review nurse based upon supporting
documentation submitted by the facility. The types of supporting documents
submitted will follow current practices and could include additional
document types depending on the information needed by the EDS review
nurse. Between July 1, 2006 and September 30, 2006, facilities will
continue to send this supporting documentation to their BQA regional
office when making the determination request, as is the current practice.
Supporting documentation will be submitted directly to EDS beginning
October 1, 2006, as these processing tasks transition to EDS. DHS and EDS
will notify facilities in advance as forms and procedures for this purpose
Determination Request Processing Transitions July 1, 2006-December 31,
- On July 1, 2006, facilities will continue to send eligibility for
nursing home care determination requests to their BQA Regional Office
using DHS form DDE-2256.
- On October 1, 2006, facilities will send eligibility for nursing
home care determination requests directly to EDS using a new EDS form
that is being developed to replace DHS form DDE-2256. DHS and EDS
will notify facilities of processing change details before October 1,
2006. BQA Regional Offices will provide processing transition
assistance to facilities until December 31, 2006.
- By December 31, 2006, the transition to EDS processing will be
complete. Nursing homes will no longer be assisted by their BQA
Regional Office in processing determination requests.
- Over the course of 2007, EDS will develop an automated portal for
communicating with nursing homes, including the electronic submission
of requests for determination of eligibility for nursing home care.
On June 5, 2006, DHS sponsored an informational web cast titled
"Nursing Home Level of Care Briefing". The web cast, with
instructions for accessing handouts, the Power Point presentation, and the
Q&As is available for viewing.
Contact Person for Policy and Program Information:
Sue Schroeder, DHS Nursing Home Policy Advisor, 608-266-6989.
Contact for Assistance with Medicaid Claims:
EDS Provider Services, 800-947-9627; or, 608-221-9883.
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