DMAS has issued a Medicaid Memo on New 1135 Waiver and Administrative Provider Flexibilities Related to COVID-19. It includes key information for nursing facilities (NFs) related to LTSS Screening, entering level of care, PASRR, MDS, and nurse aides.

Clarifications and Changes Related to the Medicaid Long Term Services and Supports (LTSS) Screening

LTSS Screening for Nursing Facilities

For individuals requesting and needing nursing facility (NF) services (including skilled, rehab, or custodial care) directly after discharge from a hospital, the requirement for a Medicaid LTSS Screening is suspended during the COVID-19 public health emergency. For admissions occurring after March 12, 2020, NFs do not need to obtain Medicaid LTSS Screening packages that would normally be required by 12VAC30-60-308, and may admit individuals without the Medicaid LTSS screening package. The individual may be admitted directly to the NF without a LTSS Screening. NFs must follow the directions below regarding the screening, evaluation and determination for specialized services for individuals who potentially have mental illness, intellectual disability or a related condition, and assure completion resident reviews. This process is known as Pre-Admission Screening and Resident Review (PASRR).

The same requirements that apply to the DMAS 97 Individual Choice form for HCBS screenings also apply in NFs: CBTs and HBTs may obtain verbal consent of the individual or authorized representative for the DMAS-97 when two LTSS screeners/individuals verify the response. Both witnesses should sign the DMAS-97 to indicate the individual’s verbal choice, and this form should be maintained with the individual’s case record.

For those individuals choosing NF care, the original DMAS-97 should be forwarded to the NF and the hospital should retain a copy. 

Entering the Level of Care

The Medicaid Portal’s Long-Term Care tab, also referred as the Automated Enrollment and Disenrollment (AE and D) portal, will not validate whether a completed LTSS Screening has occurred for NF admissions until this public health emergency has subsided. For individuals admitted after March 12, 2020 without a LTSS Screening, and for whom no special circumstance exists, NFs and health plans should check “Yes” to the question “Approved Pre-Admission Screening.” The admission date included on the form will verify that this admission occurred during the COVID-19 emergency. For all admissions covered by a special circumstance, please continue to check “No” to the “Approved Pre-Admission Screening” question but also check the special circumstance that applies.

Nursing Facilities and Preadmission Screening and Resident Review (PASRR)

DMAS is temporarily suspending PASRR Level II evaluations for 30 days after an individual’s admission. During the declared COVID-19 public health emergency, all admissions to NFs may be treated as exempted hospital discharges under 42 CFR 483.106. If the individual remains in a NF after 30 days, a resident review shall be conducted as soon as reasonably possible. NFs should follow the processes for resident review, and notify Ascend, A Maximus Company, for scheduling evaluations related to mental illness, intellectual disability or related conditions.

Minimum Data Set (MDS)

The MDS is required for both Medicare and Medicaid NFs residents. The MDS is utilized both for care planning and determining the Medicaid Resource Utilization Group (RUG) for claim pricing. Virginia is following the Medicare waiver of 42 CFR 483.20 to provide relief to skilled nursing facilities (SNFs) on the timeframe requirements for MDS assessments and transmissions. This guidance is provided for Medicaid members and may be adjusted to comport with guidance that CMS may issue pertaining to Medicare residents.

NFs should continue to complete MDS assessments for new admissions. This assessment is necessary for appropriate care planning and to establish the RUG for Medicaid billing. These assessments should be completed within 30 days (rather than 14 days) of admission. For residents transitioning from Medicare covered SNF care to Medicaid covered NF care, the NF may use the Medicaid RUG from an Omnibus Budget Reconciliation Act (OBRA) assessment within 30 days of transition. Otherwise, the NF must complete an admission assessment. However, DMAS will waive the requirement for quarterly and comprehensive assessments and significant change assessments if the clinical staff is unable to submit them timely. For Medicaid billing purposes, the provider may continue to bill the RUG from the most recent assessment. DMAS encourages NFs to complete the MDS as soon as possible after a significant change as it both informs care planning and establishes the appropriate Medicaid RUG for billing. A RUG for a significant change assessment can be billed back to the significant change as long as the assessment is within 30 days (rather than 14 days) of the significant change assessment. NFs should continue to submit the correct Assessment Reference Date (ARD) associated with the assessment that generated the RUG submitted on the claim, even though the ARD will not be taken into account during claim processing. All completed assessments should be transmitted to CMS via the Quality Improvement and Evaluation System – Assessment Submission and Processing (QIES-ASAP) application as soon as possible.

This waiver will last through the end of the emergency declaration. NFs have until the end of the following quarter to reset the quarterly assessment schedule by completing assessments on a staggered based to avoid quarterly assessments due at the same time.

Nurse Aides in Nursing Facilities

Nurse Aides in Nursing Facilities -Temporarily suspending the four-month limitation in 42 C.F.R. §483.35(d) (except for 42 C.F.R. §483.35(d)(1)(i)) for individuals working in nursing facilities as a nurse aide on a full-time basis.

SNFs and NFs may temporarily employ individuals, who are not certified nurse aides, to perform the duties of a nurse aide for more than four months, on a full-time basis. These facilities still must comply with 42 C.F.R § 483.35(c) by ensuring that nurse aides are able to demonstrate competency in the provision of nursing and nursing related services and skills and techniques necessary to care for residents’ needs, as identified through resident assessments and described in the plan of care.