NF LOC/ECS External Stakeholders Workgroup
DHS Lafayette Building, Rm. 4148
St Paul, MN

Nursing Facility Level of Care Initiative

Background

The Legislature enacted the change in NF LOC in 2009 as a part of a strategy to improve the sustainability of our publicly-funded long term service and support system, and to ensure its availability for those with greatest need. It is essential that we continue to find ways to effectively manage our public programs in order to meet the expected increasing demand for services. Federal maintenance of effort requirements has delayed implementation of the modified NF LOC until January 1, 2014 for adults aged 21 and older.

Effective January 1, 2014, for all new applicants, and for individuals currently on NF LOC programs at their next reassessment completed on or after January 1, 2014, in order to meet the criteria, a person must demonstrate at least one of the following:

• A high need for assistance in four or more activities of daily living (ADL); OR
• A high need for assistance in any one of 3 ADLs that requires 24-hour staff availability (critical ADLs of toileting, positioning or transferring); OR
• A need for daily clinical monitoring; OR
• Significant difficulty with cognition or behavior; OR
• The person lives alone and other risk factors are present.

For individuals in nursing facilities, LOC must be met at admission and at the first quarterly MDS to establish that they meet the criteria for a qualifying stay of 90 days for ongoing eligibility for MA payment of NF services. For nursing facilities, the revised LOC criteria will be applied to individuals admitted on or after October 1, 2013 (because their MDS will occur on or after January 1, 2014).

This criteria is related to MA payment for long term care and has no impact on Medicare criteria for NF payment, nor other payors (long term care insurance, or Veteran’s coverage criteria, e.g.)

In summary, individuals who will not meet the revised criteria are individuals whose primary need is for assistance with 1-3 non-critical ADLs, such as dressing or grooming, or who have no ADL needs, and who have no needs related to cognitive or clinical issues, or who do not have an ongoing need for facility-based services.

How Level of Care Will Be Determined

The LTCC assessment (to be replaced by MnCHOICES) captures all of the data necessary to establish LOC criteria based on rules related to the scores in various items (that indicate level and type of need), with the exception of criteria related to at risk for self-neglect or maltreatment. This last determination is based on the assessor’s professional judgment, and is applicable only to individuals who are (or who will be) living alone.

Within nursing facilities, level of care will be established at admission through preadmission screening, using the same criteria. The criteria based on risk related to self-neglect or maltreatment can only be established by face-to-face LTCC assessment.

Upon admission, the LOC criteria has been cross-walked to the RUGS that are established through the completion of the MDS assessment completed by the facility. Of the 36 RUGS, all but 2 contain information that meets at least one of the LOC criteria. For individuals who are assessed at these 2 lowest-needs RUGS groups (PA1 and PA2), the individual may still be determined to meet LOC through face-to-face assessment for risk of slef-neglect or maltreatment as described.

Assessed Impact 

In estimating the impact of the change in criteria, DHS completed an analysis of all individuals enrolled in EW, CADI, BI and CAC. on July 1, 2011. In this analysis DHS found the following:

• 3,068 EW participants (13%) will not meet the modified NF LOC criteria.
  • Of those, 2,822 (92%) live in their own home or apartment. Of the remaining 246 (8%), 5 individuals are in foster care settings and the rest live in the home of a relative.
  • Of the 3,068 who do not meet the modified criteria, 337 individuals (11%) were or are receiving customized living or 24 hour customized living.
• Of the 3,100 Alternative Care (or AC) participants, 268 (8.5%) will not meet the modified NF LOC criteria. All AC participants live in their own home or apartment, or in the home of a relative.
• All BI and CAC enrollees met at least one criteria
• About 3% of CADI (500 of almost 17,000) of individuals did not meet any LOC criteria

Implementation

Minnesota will implement the new NF LOC during 2014 on a rolling basis for HCBS, as an individual’s need for an annual assessment arises, so transitions take place over a 12 month period.

For nursing facility residents, individuals admitted on or after October 1, 2013 will be assessed using the revised criteria at their first MDS that occurs on or after January 1, 2014.

For private pay individuals who spend down to MA while in the facility, the MDS used to determine LOC will be the most recent MDS assessment completed before the effective date of MA eligibility for payment of LTC services.

Available Supports

Individuals will have several programs and alternatives available to them. Using the EW group as an example:

Effect on MA eligibility: Of the 3,068 Elderly Waiver participants in the sample who did not meet the modified level of care criteria:

• 2,853 (93%) will remain eligible for Medical Assistance coverage for basic health care, including state plan services like personal care assistance (PCA). 2,577 individuals remain eligible for Medical Assistance without a spenddown. The vast majority will receive their MA services through a health plan.
• 276 individuals will remain eligible for Medical Assistance with a spenddown.
• 215 (7%) will lose eligibility for Medical Assistance.
• Nearly all CADI would retain MA eligibility.

Access to alternative services:

• For individuals of all ages who remain eligible for MA, PCA services will be available to meet ADL needs.
• For individuals age 65 and older, Essential Community Supports has been approved by the legislature for non-MA individuals age 65 and older who need one of the ECS services and who meet AC financial eligibility criteria. It will provide up to $400 per month for certain services that are most-needed to maintain independence in the community. These services were selected based on the analysis of services that individuals in the July 2011 sample who did not meet the modified criteria were most likely to be receiving.
• Upon federal approval, for individuals who remain eligible for MA and who do not meet the requirement for PCA services, Essential Community Supports will be available to address their service needs. ECS for MA individuals is limited to those enrolled in an HCBS program at the time of implementation who subsequently lose waiver eligibility solely because of the revised LOC criteria (i.e. it is a transition program).
• In the federal request, ECS would also be available to individuals under 65 who lose MA as a result of losing LTC eligibility, who need an ECS service and who meet AC financial eligibility criteria.
• All older individuals are also eligible for Older Americans Act services funded through local Area Agencies on Aging as well as services funded through DHS Community Services/Community Services Development grants. Available services include but are not limited to chore, homemaker, nutrition services (including congregate dining and home delivered meals), transportation, and supports for caregivers.
• Return to Community and Minnesota Moving Home are strategies to identify individuals who want to return to the community and may need assistance to do so.

Communication and Training

Lead agency and provider communications are included in the work plan. This includes provision of information about individuals on HCBS who, based on their most recent assessment, may not meet the revised LOC at their next reassessment that occurs on or after January 1, 2014.

Participant communications include preparation of consumer materials that clarify eligibility for MA-funded LTC programs (and AC), as well as revisions to exiting forms with notice and appeal rights information.

Referral protocols are being developed to provide support to staff in connecting individuals to alternative community supports and housing.