The PASRR Technical Assistance Center helps states fulfill the goals of Preadmission Screening and Resident Review

Is the state obligated to provide specialized services to private pay individuals?

PASRR is required for all individuals who apply for admission to a Medicaid-certified NF, regardless of insurance type (Medicaid, Medicare, or private pay). Thus, private pay applicants who test positive at Level I could be found at Level II to need specialized services. By definition, however, all services supplied to individuals who have private insurance are not covered by the state. This includes specialized services, whatever those are determined to be.

Nonetheless, the state should help to arrange specialized services for private pay residents who need them, for two reasons.

First, from a person-centered perspective, residents will get much better care – and have better outcomes – if they receive assistance securing the services they need to thrive.

Second, many residents who enter NFs with private insurance ultimately "spend down" and become Medicaid-eligible. At that point, it would be the state's responsibility to pay for specialized services (whether those are Medicaid services or services provided with state-only funds). It is in the state's interest, then, to help arrange SS so that the individual is getting what he or she needs at the moment they transition from receiving benefits under private insurance to receiving benefits under Medicaid. A seamless transition from private pay to Medicaid would result in better outcomes for the individual and (likely) lower costs for the state. Without specialized services, an individual's MI or ID status could deteriorate, and it could be quite costly to stabilize the individual and help him or her improve.

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