Health, Health Care Financing, Coverage and Reimbursement Policy

Section R414-501-2

Definitions

Notice of Proposed Rule

(Amendment)

DAR File No.: 36186
Filed: 05/14/2012 04:04:20 PM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this amendment is to update the definition of "Significant Change" in the rule text to reflect Medicaid policy on preadmission screening for nursing facility admission.

Summary of the rule or change:

This amendment updates the definition of "Significant Change" to include a provision for a mental illness or an intellectual disability or related condition.

State statutory or constitutional authorization for this rule:

• 42 U.S.C. 1396r
• Section 26-1-5
• Section 26-18-3

Anticipated cost or savings to:

the state budget:

There is no impact to the state budget because this change only updates a definition in the rule text to reflect Medicaid policy on preadmission screening for nursing facility admission.

local governments:

There is no impact to local governments because they neither evaluate residents for nursing facility admission nor provide nursing facility services to Medicaid recipients.

small businesses:

There is no impact to small businesses because this change only updates a definition in the rule text to reflect Medicaid policy on preadmission screening for nursing facility admission.

persons other than small businesses, businesses, or local governmental entities:

There is no impact to nursing facilities, providers and residents because this change only updates a definition in the rule text to reflect Medicaid policy on preadmission screening for nursing facility admission.

Compliance costs for affected persons:

There is no impact to a single nursing facility, provider or resident because this change only updates a definition in the rule text to reflect Medicaid policy on preadmission screening for nursing facility admission.

Comments by the department head on the fiscal impact the rule may have on businesses:

Streamlining policy may have a positive fiscal impact on providers as reporting is simplified. Public comment will be carefully evaluated.

David Patton, PhD, Executive Director

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Health
Health Care Financing, Coverage and Reimbursement Policy
CANNON HEALTH BLDG
288 N 1460 W
SALT LAKE CITY, UT 84116-3231

Direct questions regarding this rule to:

• Craig Devashrayee at the above address, by phone at 801-538-6641, by FAX at 801-538-6099, or by Internet E-mail at [email protected]

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

07/02/2012

This rule may become effective on:

07/09/2012

Authorized by:

David Patton, Executive Director

R414. Health, Health Care Financing, Coverage and Reimbursement Policy.

R414-501. Preadmission Authorization, Retroactive Authorization, and Continued Stay Review.

R414-501-2. Definitions.

In addition to the definitions in Section R414-1-1, the following definitions apply to Rules R414-501 through R414-503:

(1) "Activities of daily living" are defined in 42 CFR 483.25(a)(1), and further includes adaptation to the use of assistive devices and prostheses intended to provide the greatest degree of independent functioning.

(2) "Categorical determination" means a determination made pursuant to 42 CFR 483.130 and ATTACHMENT 4.39-A of the State Plan.

(3) "Code of Federal Regulations (CFR)" means the most current edition unless otherwise noted.

(4) "Continued stay review" means a periodic, supplemental, or interim review of a resident performed by a Department health care professional either by telephone or on-site review.

(5) "Discharge planning" means planning that ensures that the resident has an individualized planned program of post-discharge continuing care that:

(a) states the medical, functional, behavioral and social levels necessary for the resident to be discharged to a less restrictive setting;

(b) includes the steps needed to move the resident to a less restrictive setting;

(c) establishes the feasibility of the resident's achieving the levels necessary for discharge; and

(d) states the anticipated time frame for that achievement.

(6) "Health care professional" means a duly licensed or certified physician, physician assistant, nurse practitioner, physical therapist, speech therapist, occupational therapist, registered professional nurse, licensed practical nurse, social worker, or qualified mental retardation professional.

(7) "Medicaid resident" means a resident who is a Medicaid recipient.

(8) "Medicaid admission date" means the date the nursing facility requests Medicaid reimbursement to begin.

(9) "Mental retardation" is defined in 42 CFR 483.102(b)(3) and includes "persons with related conditions" as defined in 42 CFR 435.1009.

(10) "Minimum Data Set (MDS)" means the standardized, primary screening and assessment tool of health status that forms the foundation of the comprehensive assessment for all residents in a Medicare or Medicaid certified long-term care facility.

(11) "Nursing facility" is defined in 42 USC. 1396r(a), and also includes an intermediate care facility for people with mental retardation as defined in 42 USC 1396d(d).

(12) "Nursing facility applicant" is an individual for whom the nursing facility is seeking Medicaid payment.

(13) "Preadmission Screening and Resident Review (PASRR) Level I Screening" means the preadmission identification screening described in Section R414-503-3.

(14) "Preadmission Screening and Resident Review (PASRR) Level II Evaluation" means the preadmission evaluation and resident review for serious mental illness or mental retardation described in Section R414-503-4.

(15) "Physician Certification" is a written statement from the Medicaid resident's physician that certifies the individual requires nursing facility services.

(16) "Resident" means a person residing in a Medicaid-certified nursing facility.

(17) "Serious mental illness" is defined by the State Mental Health Authority.

(18) "Significant change" means a major change in the resident's physical, mental, or psychosocial status that is not self -[ ]limiting, impacts on more than one area of the resident's health status, and requires interdisciplinary review, [or ]revision of the care plan[.], or may require a referral to a preadmission screening resident review if a mental illness or intellectual disability or related condition is suspected or present.

(19) "Skilled care" means those services defined in 42 CFR 409.32.

(20) "Specialized rehabilitative services" means those services provided pursuant to 42 CFR 483.45 and Section R432-150-23.

(21) "Specialized services" means those services provided pursuant to 42 CFR 483.120 and ATTACHMENT 4.39 of the State Plan.

(22) "United States Code (USC)" means the most current edition unless otherwise noted.

(23) "Working days" means all work days as defined by the Utah Department of Human Resource Management.

 

KEY: Medicaid

Date of Enactment or Last Substantive Amendment: [June 7, 2011]2012

Notice of Continuation: August 20, 2009

Authorizing, and Implemented or Interpreted Law: 26-1-5; 26-18-3