CurrentHealthPartnersPolicy N/A

MSHO / MSC+ / SNBC Nursing Facility Service Authorization Process

Governs nursing facility service authorization, pre-admission screening (PAS), OBRA/PASSR processes, billing/appeals routing, and waiver impacts for MSHO, MSC+, and SNBC enrollees within HealthPartners.

Policy Summary

PayerHealthPartners

PolicyMSHO / MSC+ / SNBC Nursing Facility Service Authorization Process

Policy CodePolicy N/A

Change TypeNo material change

Effective DateFeb 19, 2019

Next Review Date

Key ActionMake all PAS referrals online at www.mnaging.org so Senior LinkAge Line can forward referrals for LOC and OBRA Level I determination.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

up to 180 daysMCO NF days (MSHO/MSC+)

up to 100 daysMCO NF days (SNBC)

bulletin #17-25-06PAS guidance

after 90 daysMoving Home MN eligibility

3Appendices

~30

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MCO Responsibility and Screening Requirements

MCO NF day responsibility

MCO responsibility for NF days and initial eligibility checks

Check MN-ITS to determine Medical Assistance (MA) eligibility and managed care enrollment.

MSHO and MSC+ program plans may be responsible for up to 180 nursing facility (NF) days for enrollees; SNBC program plans may be responsible for up to 100 NF days.

Contact the managed care organization (MCO) to determine MCO liability for individual enrollees.

Contact Member Services for phone numbers where applicable.

Screening, OBRA, and assessment requirements

Screening and assessments required prior to or upon admission

Make all pre-admission screening (PAS) referrals online at www.mnaging.org; Senior LinkAge Line retrieves referral information and forwards it to the MCO (and county of financial responsibility when applicable) for determination of need, level of care (LOC), and OBRA Level I.

OBRA Level II for mental illness (MI) follows PASSR bulletin #17-25-06; OBRA Level II for developmental disability (DD) is conducted by the county of financial responsibility (CFR).

For waiver and home-care contexts, the MCO or CFR conducts assessments and authorizations as specified by the waiver type; MCO authorizes home health agency services where applicable.

Waiver impacts, relocation, and transition

Waiver and program impacts for NF admission

Impact on waiver service agreements varies by waiver: CFR case manager will close service line item agreements upon admission for CAC, CADI, BI, and DD waivers; MCO care coordinator will enter exit screening documents after 30 days for some waivers per program rules.

Moving Home MN and other transition programs: eligibility and timing (for example, Moving Home MN considerations after 90 days) are determined by DHS and processed by the MCO or CFR depending on program specifications.

Uncompensated transfer penalty and relocation/transition responsibilities differ by program: MCO pays state-plan services (including HHA) in some contexts; LTC not covered by MCO in other contexts and the individual may be responsible. Contact care coordinator and financial worker for transition and financial details.

Nursing facility admission screening

Administrative requirement

All individuals entering a nursing facility must receive Pre-admission Screening (PAS) and PASRR screening as required by federal and state law, regardless of anticipated length of stay or payer source.

What Providers Must Do

Note

Pre-admission screening referrals

Make all Pre-Admission Screening (PAS) referrals online at www.mnaging.org. The Senior LinkAge Line® retrieves referral information and forwards it to the responsible MCO (and county of financial responsibility when applicable) for determination of level of care (LOC) and OBRA Level I screening. For DD waiver referrals, DHS approval is required and the lead agency must obtain approval on the DD screening document (full team screening) through MMIS.

Applicable programs: MSHO, MSC+, SNBC
Senior LinkAge Line® forwards referrals to MCO and CFR when required (e.g., CAC/CADI/BI and DD waivers)
DD waiver: lead agency must obtain DHS approval via MMIS

Billing Rule

Billing and appeals routing

Follow these billing and appeals routing rules for Medicare-covered days and related appeals: For MSHO enrollees, bill the MCO and direct appeals regarding Medicare-covered days or to contest Medicare decisions to the MCO. For MSC+ enrollees, bill original Medicare for Medicare-covered days and file appeals of original Medicare decisions with Medicare. Ensure billing/appeals handling aligns with the enrollee’s program (MSHO vs MSC+) and waiver/case management status.

Key Terms and Abbreviations

PAS (Pre-admission screening) — Definition and referral process

DefinitionPre-admission screening (PAS): A telephone screening that checks for developmental disabilities or mental illness and determines level of care (LOC); part of OBRA Level I screening.

How to referMake all PAS referrals online at www.mnaging.org; Senior LinkAge Line retrieves referral information and forwards it to the MCO (and CFR when applicable).

PurposeEnsures individuals entering a nursing facility are screened for LOC and for evidence of serious mental illness or intellectual/developmental disability as required by federal/state law.

OBRA Level II — Definition and relation to PASSR guidance

DefinitionOBRA Level II: Second-level screening for serious mental illness (MI) or developmental disability (DD).

MI Level II guidance

Policy Summary

PayerHealthPartners

PolicyMSHO / MSC+ / SNBC Nursing Facility Service Authorization Process

Policy CodePolicy N/A

Change TypeNo material change

Effective DateFeb 19, 2019

Next Review Date

Key ActionMake all PAS referrals online at www.mnaging.org so Senior LinkAge Line can forward referrals for LOC and OBRA Level I determination.

SourceLink

On This Page

MSHO: MCO handles billing and appeals for Medicare-covered days (contact Member Services to confirm liability)
MSC+: Original Medicare is billed and Medicare handles appeals for original Medicare decisions
Contact Member Services to determine MCO liability: MSHO: 952-967-7029 or 888-820-4285; MSC+: 952-967-7998 or 886-885-8880

MI OBRA Level II follows PASSR bulletin #17-25-06.

DD Level II responsibilityOBRA Level II for DD is conducted by the county of financial responsibility (CFR).

BI (Brain Injury Waiver)

DefinitionBI (Brain Injury Waiver): Medical Assistance program for people with traumatic, acquired, or degenerative brain injury who require NF-level specialized services or neurobehavioral hospital care.

PAS handlingWhen a person is in the community with BI waiver, make PAS referrals online at www.mnaging.org; Senior LinkAge Line forwards referrals to the MCO and CFR as appropriate.

CAC (Community Alternative Care Waiver)

DefinitionCAC (Community Alternative Care Waiver): Medical Assistance program for chronically ill and medically fragile people who require hospital-level care.

PAS processMake PAS referrals online at www.mnaging.org; Senior LinkAge Line forwards referrals to the MCO and CFR for LOC and OBRA Level I determinations when CAC is involved.

CADI

DefinitionCADI (Community Access for Disability Inclusion Waiver): Program for people with disabilities who require nursing facility level of care.

PAS handlingFor members in CADI, make PAS referrals online at www.mnaging.org; Senior LinkAge Line forwards referrals to the MCO and CFR as applicable for LOC and OBRA Level I.

CFR (County of financial responsibility)

DefinitionCFR = County of financial responsibility: The county responsible for payment of a person's social services.

Role in PAS/OBRAWhen applicable (e.g., CAC, CADI, BI, DD waivers), Senior LinkAge Line forwards PAS referrals to the CFR for determination of need, LOC, and OBRA Level I.

COL (County of location)

DefinitionCOL = County of location: The county where the person served is located.

Operational noteCOL is referenced for coordination of face-to-face screening timelines and OBRA processes where applicable.

COR (County of residence)

DefinitionCOR = County of residence: The county where the person served is currently living.

UseCOR may be used to determine county responsibilities for services and coordination of transitions.

DD (Developmental Disability Waiver)

DefinitionDD = Developmental Disability Waiver: MA program for persons with developmental disabilities or related conditions who require ICF/DD level of care.

DD Level IIOBRA Level II for DD is conducted by the county of financial responsibility (CFR); DHS approval is required for DD screening team results entered through MMIS.

DHS (Minnesota Department of Human Services)

DefinitionDHS = Minnesota Department of Human Services.

Program roleDHS issues PAS/PASSR requirements and bulletins (e.g., PASSR bulletin #17-25-06) that guide OBRA/PAS processes.

ECS (Essential Community Supports)

DefinitionECS = Essential Community Supports: Program available to people needing one or more services to live in the community who do not need nursing home level of care.

ContextECS is an alternative for people who do not require NF-level care and may affect PAS/placement decisions.

EW (Elderly Waiver)

DefinitionEW = Elderly Waiver: Program for people over 65 who require nursing facility level of care and choose to reside in the community.

PAS processFor individuals receiving EW services, make PAS referrals online at www.mnaging.org; Senior LinkAge Line forwards to the MCO for LOC and OBRA Level I.

HCN (Home care nursing)

DefinitionHCN = Home care nursing: Formerly known as private duty nursing (PDN).

InclusionHome care nursing is included in the broader category of home care services used when assessing community supports prior to NF placement.

HHA services (Home health agency services)

DefinitionHHA services = Home health agency services, including skilled nurse visit (SNV), home health aide (HHA), physical therapy (PT), speech therapy (SP), occupational therapy (OT), and respiratory therapy (RT).

ContextHHA services are part of home care services considered when determining LOC and supports before NF admission.

Home care services

DefinitionHome care services = All HHA services plus home care nursing (HCN) and personal care assistance (PCA).

RelevanceHome care services are considered in PAS and placement decisions for individuals in the community.

LOC (Level of care)

DefinitionLOC = Level of care: Care and services associated with a particular facility type.

Use in PASPAS determines LOC as part of the OBRA Level I screening to ensure appropriate placement in a nursing facility when needed.

LTC (Long-term care)

DefinitionLTC = Long-term care: Services providing rehabilitative, restorative, or ongoing skilled nursing care and assistance with activities of daily living.

ScopeLTC encompasses nursing facility services evaluated through PAS/OBRA processes.

MI (Mental Illness)

DefinitionMI = Mental Illness; refers to OBRA Level II evaluative report form for people with mental illness.

OBRA Level II for MIMI Level II evaluations follow PASSR bulletin #17-25-06.

MCO (Managed care organization)

DefinitionMCO = Managed care organization.

Operational roleSenior LinkAge Line forwards PAS referrals to the MCO responsible for determination of need, LOC, and OBRA Level I; contact Member Services to determine MCO liability when needed.

MSC+ (Minnesota Senior Care Plus)

DefinitionMSC+ = Minnesota Senior Care Plus: Program similar to MSHO for long-term care services but does not include Medicare services or Part D.

MCO NF day responsibilityMSHO and MSC+ program plans may be responsible for up to 180 nursing facility days; contact MCO to determine specific liability.

MSHO (Minnesota Senior Health Options)

DefinitionMSHO = Minnesota Senior Health Options: Voluntary Minnesota managed health care program for people 65+ who are eligible for Medical Assistance and Medicare Parts A and B.

Billing noteFor MSHO, bill/appeal Medicare-covered days to the MCO as specified in program guidance.

NF (Nursing facility)

DefinitionNF = Nursing facility: Licensed residence for individuals needing a higher level of medical care than assisted living.

PAS requirementAll individuals entering a nursing facility must receive PAS and PASRR screening as required by federal and state law.

OBRA (Omnibus Budget Reconciliation Act 1987)

DefinitionOBRA = Omnibus Budget Reconciliation Act 1987: Federal law requiring screening and review of persons with suspected developmental disability who seek admission to a nursing facility.

Relation to PAS/PASRROBRA requires PAS/PASRR processes; OBRA Level II evaluations are conducted per PASSR guidance or by CFR for DD.

PAS (Pre-admission screening) — term entry

Short term definitionPAS: Pre-admission screening — telephone screening for developmental disabilities or mental illness and LOC determination; part of OBRA Level I screening.

Actionable referral stepMake all PAS referrals online at www.mnaging.org; Senior LinkAge Line retrieves and forwards referrals to the MCO and CFR as appropriate.

PASRR (Pre-admission screening and resident review)

DefinitionPASRR = Pre-admission screening and resident review: Ensures NF applicants are screened for serious MI or ID/DD/related conditions and placed appropriately and receive necessary services while in the NF.

Regulatory requirementFederal and state laws require PASRR screening for all individuals entering a nursing facility.

PCA (Personal care assistance)

DefinitionPCA = Personal care assistance: Services to help people with day-to-day activities in their home and community.

Relation to home carePCA is included in home care services and is considered when assessing alternatives to nursing facility placement.

SNBC (Special Needs BasicCare)

DefinitionSNBC = Special Needs BasicCare: Voluntary Minnesota managed care program for people with disabilities ages 18–64 who are eligible for Medical Assistance; Medicare-eligible members must have Parts A and B.

MCO NF day responsibilitySNBC program plans may be responsible for up to 100 nursing facility days; contact Member Services to determine MCO liability for specific enrollees.