Utah Admin. Code R414-502-3 - Approval of Level of Care
(1) The
Department shall document that at least two of the following factors exist when
it determines whether an applicant has mental or physical conditions that
require the level of care provided in a nursing facility or equivalent care
provided through a Medicaid home and community-based waiver program:
(a) due to diagnosed medical conditions, the
applicant requires substantial physical assistance with daily living activities
above the level of verbal prompting, supervising, or setting up;
(b) the attending physician has determined
that the applicant's level of dysfunction in orientation to person, place, or
time requires nursing facility care, or equivalent care provided through a
Medicaid home and community-based waiver program ; or
(c) the medical condition and intensity of
services indicate that the care needs of the applicant cannot be safely met in
a less structured setting, or without the services and supports of a Medicaid
home and community-based waiver program.
(2) The Department shall determine whether at
least two of the factors described in Subsection (1) exist by reviewing the
following clinical documentation:
(a) a
current history and physical examination completed by a physician;
(b) a comprehensive resident assessment
completed, coordinated, and certified by a registered nurse;
(c) a social services evaluation that meets
the criteria in 42 CFR
456.370 and completed by a person licensed as
a social worker, or higher degree of training and licensure;
(d) a written plan of care established by a
physician;
(e) a physician's
written certification that the applicant requires nursing facility placement;
and
(f) documentation indicating
that less restrictive alternatives or services to prevent or defer nursing
facility care have been explored.
(3) If the Department finds that at least two
of the factors described in Subsection (1) exist, the Department shall
determine whether the applicant meets nursing facility level of care and is
medically-approved for Medicaid reimbursement of nursing facility services or
equivalent care provided through a Medicaid home and community-based waiver
program. Meeting medical eligibility for nursing facility services does not
guarantee Medicaid payment. Financial eligibility and other home and
community-based waiver targeting criteria apply.
(4) During the Coronavirus (COVID-19) public
health emergency period, an individual may temporarily meet nursing facility
level of care for a period of illness, if the individual:
(a) is COVID-19 positive;
(b) is experiencing active COVID-19 symptoms;
or
(c) is admitting directly from:
(i) a licensed, assisted living
facility;
(ii) a licensed
intermediate care facility for people with intellectual disabilities;
or
(iii) an acute care, inpatient
hospital.
Notes
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