CMS generally reimburses nursing facility level of care (NF LOC) determinations at the 50% match rate. However, states that integrate their NF LOC determination activities with PASRR as described below can receive the enhanced 75% match rate.
While many states separate NF LOC determinations from PASRR decisions -- a fully legal decision -- the final rule for PASRR contemplated that the medical necessity determination and the MI/ID decision would be made in concert. In programs that integrate NF LOC and PASRR, CMS allows NF LOC activities to be claimed at the enhanced 75% match if:
- The process does not lead to undesirable delays in the completion of a Level II evaluation, summary of findings, or determination;
- The process does not duplicate other state NF LOC determination activities;
- NF LOC determinations for individuals receiving a PASRR Level II evaluation are made within the context of suspected MI/ID conditions; and
- Decisions about individuals’ NF LOC needs and their need for disability-specific services (specialized rehabilitative services and specialized services) are made together.
NF LOC screenings for persons with a PASRR disability are fundamentally different than NF LOC screenings conducted for persons without a PASRR disability. Because functional limitations are often inherently tied to the MI/ID condition, NF LOC considerations in states with high reliance on functional (rather than medical) criteria are significantly more complex for persons with MI and/or ID.
When PASRR is done correctly, the presence of a PASRR-related disability impacts the interpretation of NF LOC needs. In turn, individuals’ NF LOC needs affect the kinds of disability-specific recommendations identified in the PASRR Level II Summary of Findings report. To do a good job developing the PASRR Summary of Findings report and recommendations, all of the factors that contribute to the assessment of an individual’s NF LOC needs must be considered.
Please request assistance if you have additional or state-specific questions about how to claim the enhanced 75% match for NF LOC activities.