1006 Eligibility Review

Policy

Eligibility review is an important part of the Pre-Admission Screening (PAS) assessment process. An eligibility review is conducted when the final PAS score may not be an accurate reflection of the customer’s need for Skilled Nursing Facility (SNF) or Intermediate Care Facility (ICF) level of care.

Eligibility reviews are mainly used for PAS assessments that score below the eligibility threshold but are also used in certain situations when the score is above the eligibility threshold.

There are two types of Eligibility Reviews:

·        PAS Analyst Review Consultant (PARC) reviews, and

·        Physician Review.

1) PAS Analyst Review Consultant (PARC) Review

A PAS Analyst Review Consultant (PARC), reviews PAS assessments that have been reviewed and referred by a Benefits and Eligibility Manager (BEM) in the following situations:

·        PAS Reassessments scoring below the eligibility threshold but that appear eligible. If the PARC review does not confirm that the customer remains medically eligible, the PAS is then referred to a physician consultant for review.

·        Initial elderly or physically disabled (EPD) PAS assessments for customers whose PAS score meets the eligibility threshold and have a both a medical condition and a psychiatric condition that may be contributing to the customer’s need for care.  If the PARC review is unable to determine if the customer’s psychiatric condition is a contributing factor in meeting the eligibility threshold, the case will be referred to a physician consultant.

2) Physician Review

A physician consultant reviews the PAS assessment and available medical records, and uses professional judgment to determine whether or not a customer has a developmental disability or a non-psychiatric medical condition that by itself, or in combination with other medical conditions, places the customer at immediate risk of institutionalization.

The physician consultant reviews initial PAS assessments referred after review by a Benefits and Eligibility Manager or PARC, as well as all PAS reassessments that are no longer scoring eligible. After reviewing the PAS for accuracy and completeness, the Benefits and Eligibility Manager will request a physician review in the following circumstances:

·        The EPD PAS score is less than the threshold of 60 but is at least 56;

·        The DD PAS score is less than threshold of 40 but is at least 38;

·        A customer scores below the threshold (60 for EPD and 40 for DD) but the PAS assessor and Benefits and Eligibility Manager have reasonable cause to believe that the customer’s functional abilities or medical conditions may place the  customer at immediate risk of institutionalization;

·        The EPD PAS score is less than the threshold and the customer has a documented diagnosis of autism or autistic-like behavior;

·        The EPD PAS score is at or above the threshold, but the customer has a serious mental illness, as defined in ARS § 36-550, that may be contributing to the need for care at a level provided in a nursing facility or intermediate care facility;

·        The EPD PAS score is at or above the threshold for a customer on AHCCCS in an acute care program, but the Benefits and Eligibility Manager has reasonable cause to believe that the applicant’s condition is improving and needs less than 90 days of institutional care;

·        The customer has a physical disability and is less than 12 years of age;

·        The customer is under six months of age;

·        An ALTCS customer is living in a SNF or ICF and at reassessment, no longer meets the eligibility threshold score for ALTCS or ALTCS Transitional, as defined in MA1010; and

·        An ALTCS DD customer is determined to no longer be DD-eligible by the DES Department of Developmental Disabilities and does not meet the EPD scoring threshold.

The physician consultant reviews and considers the following when determining medical eligibility:

·        Dependence on others for help with activities of daily living;

·        Delay in development;

·        Continence;

·        Orientation;

·        Behavior;

·        Medical conditions, including stability and prognosis of the condition;

·        Any medical nursing treatment provided to the customer including skilled monitoring, medication, and therapeutic procedures;

·        The degree to which the customer must be supervised;

·        The skill and training required of the customer’s caregiver; and

·        Any other significant factors that impact the individual case.

If the physician consultant cannot make the determination from the PAS assessment and the available medical records, the physician consultant may conduct a face-to-face review with the customer or contact others familiar with the customer’s needs, including a primary care physician or other caregiver, to make the determination.

The physician consultant must document the reasons for the determination in the physician review comment section of the PAS assessment.

Definitions

Legal Authority