Library: Policy

317:35-19-18. Change in level of long-term medical care

Revised 6-1-07

(a) When a member is receiving Personal Care services and requests nursing facility care or when a member is in a nursing facility and requests Personal Care services, a new Uniform Comprehensive Assessment Tool (UCAT) is required.  The UCAT is updated if the member is in the nursing facility and requests ADvantage waiver services.  No new medical decision is needed.  Also, no new medical decision is needed for admission to a nursing facility from home if the period of absence from the nursing facility is less than 90 days.  No new medical decision is needed if the member loses financial eligibility but maintains medical eligibility by having a current medical decision and by remaining in the facility during the period of financial ineligibility.

(b) When there is a decision that a member approved for one level of long term care is eligible for a different level of care, the local office is advised by update of the file.  If the change is from facility care to Personal Care, a new UCAT, Part III care plan, service plan, and other required forms are submitted to the area nurse, or nurse designee.  If the Personal Care member requests a decision regarding facility care prior to admission to a facility, the LTC nurse is responsible for submitting the UCAT, Part III, and Form LTC-300R to the area nurse, or nurse designee for a decision.  When the area nurse, or nurse designee, determines that a nursing care member no longer needs this level of care, payment may be continued while the member, or other responsible person, makes other arrangements.  The length of such continuation of payment depends upon the circumstances, but must allow time for the appropriate advance notice to the member and cannot exceed 60 days from the date of the decision.