Title 16
20000 Medicaid Long Term Care
20102 Medical Eligibility Determinations
The first of two steps in the application process is to determine medical eligibility. This is usually determined by Pre-Admission Screening (PAS). Referrals to PAS may come from the family of the applicant as well as other sources.
20102.1 Four Levels of Nursing Facility Care
There are four levels of nursing facility care for which Medicaid can make payment to qualified providers.
20102.1.1 Skilled Nursing Facility Level of Care
20102.1.2 Intermediate Nursing Facility Level of Care
20102.1.3 Intermediate Care - Facility for the Mentally Retarded
20102.1.4 Intermediate Care - Facility for Mental Disease
20102.1.1 Skilled Nursing Facility Level of Care
Skilled Nursing Facility Level of Care - Skilled nursing facility (SNF) is an institutional setting which provides skilled nursing or rehabilitation services for mental or physical conditions. Such a setting includes availability of around the clock professional nursing observations, assessment or intervention.
Super Skilled indicates a payment methodology to accommodate respirator and some other skilled level patients as recommended by the DSS Medical Operations Administrator.
20102.1.2 Intermediate Nursing Facility Level of Care
Intermediate Nursing Facility Level of Care Intermediate care nursing facility (ICF) is an institutional setting in which nursing and allied health care and support services are provided on a daily basis. Such services are supervised by but not necessarily given by a licensed nurse.
20102.1.3 Intermediate Care Facility for the Mentally Retarded Level of Care
Intermediate Care Facility for the Mentally Retarded (ICF/MR) An intermediate care facility for the mentally retarded (ICF/MR) is a residential setting which offers comprehensive habilitative and support services to persons with mental retardation or related conditions. To qualify for an ICF/MR level of care, individuals exhibit significant deficits in age-appropriate functioning in multiple domains. As a consequence, they require frequent assistance or supervision to competently or safely engage in activities of daily living (ADLs).
20102.1.4 Intermediate Care Facility for Mental Disease Level of Care
Intermediate Care Mental Disease Level of Care (ICF/MD) results from a primary psychiatric diagnosis and indicates a need for services in an institution licensed to care for psychiatric patients. Medicaid vendor payments can only be made for persons who are 65 years of age and older.
An intermediate care facility for mental disease (ICF/MD) is a residential setting which offers comprehensive clinical and support services to persons with significant behavioral health disorders. Such disorder must compromise functioning in multiple areas and require frequent or intensive medical or behavioral interventions (e.g., drug therapy; professional counseling; behavior management techniques).
20102.2 Medical Necessity Procedures
There are two ways to determine the medical necessity of nursing facility care. These are:
20102.2.1 Pre-Admission Screening
20102.2.2 Medical Review Team
20102.2.1 Pre-Admission Screening
The Medicaid Long Term Care Unit's Pre-Admission Screening team performs a level of care determination for individuals in hospitals or in the community who will be entering a privately funded or public skilled or intermediate care facility. This includes individuals currently residing out-of-state who are seeking nursing facility placement in Delaware. The determination is made in accordance with guidelines established by the Medicaid program. The initial determination for applicants requiring a super skilled level of care is made by PAS. The Medical Review Team then confirms the determination of the necessity of super skilled care.
20102.2.2 Medical Review Team
The Medical Review Team determines the level of care for the following groups:
individuals seeking out of state inpatient rehabilitation hospital care,
superskilled Reimbursement level of care,
Disabled Children’s Program.
A MAP-25 (Comprehensive Medical Report) is completed by the attending physician and is submitted to the State Office Medical Review Team along with any supporting documentation for approval.
