Long Term Care Services

Long Term Care Benefit Overview

• Health Plan covers long-term care benefits for members who qualify.
• Long term care services require authorization based on medical necessity.
• For those members that LTC services are deemed medically necessary, Health Plan will assist members and their providers in locating in a health care facility that provides the level of care most appropriate to member’s medical needs.
• Health Plan offers support to members transitioning through various levels of care.

The Preadmission Screening Resident Review (PASRR)

The Preadmission Screening Resident Review (PASRR) is a federal requirement (Code of Federal Regulation (CFR), Title 43, Sections 483.100-138) for all members initially entering a SNF to determine if they have a possible Serious Mental Illness (SMI)or have an Intellectual Disability/Development Disability/Related Conditions (IDD/DD/RC). The Federal regulation indicates that a PASRR is required for all members who apply for admission into a Medi-Cal certified Skilled Nursing Facility (SNF), regardless of the individual’s insurance type or payment source. This requirement also applies to members who already reside in a Medi-Cal certified SNF.

PASRR Responsibilities:
General Acute Care Hospital (GACH):

• required to perform the Preadmission Screening Resident Review (PASRR) on any member being discharged to a SNF.

Skilled Nursing Facilites (SNF):

• required to perform the PASRR when a member is being admitted directly from the community.
• required to initiate Resident Review (RR) by submitting Level 1 Screening only when there is a significant change in the member’s physical or mental condition.

Skilled Nursing Facilities (SNF) – Alerts (hpsj.com)

Authorization Timeline Process for Facilities 

1. The authorization request will be reviewed and processed within the specified timelines
2. The facility will receive an initial notification within 24 hours of the decision via fax or phone for all decisions. The facility will also receive a Notice of Action (NOA) by mail , in addition to the initial notification for adverse determinations within 2 business days of the decision. 

3. The facility will receive an initial notification within 24 hours of the decision via fax or phone for all decisions. The facility will also receive a Notice of Action (NOA) by mail , in addition to the initial notification for adverse determinations within 2 business days of the decision.

Required Documentations 

• Facesheet 
• Current MDS 
• Current MD Orders 
• PASRR 
• Discharge planning notes, if indicated by the Q section 

Non-Emergency Medical Transportation (NEMT) for members in Long Term Care

• Non-Emergency Medical Transportation (NEMT) is available for a member with a medical and/or physical condition that makes transportation by ordinary public or private transportation medically contraindicated, and transport is needed to obtain medical care. NEMT must be prescribed in writing by the member’s treating Physician, Physician Assistant or Certified Nurse Midwife and be accompanied by a completed Physician Certification Form (PCS).

For non-emergency transportation, if a member’s medical and physical condition requires any of the following, then the member requires NEMT:

1. Supine or prone position.
2. Member incapable of sitting in a private vehicle, taxicab, or other form of public transportation for the time necessary to transport to and from their appointment.
3. The member needs to be transported in a wheelchair or assisted to and from their residence, a vehicle, and a place of treatment because of disabling physical or mental limitation.

If a member’s medical and physical condition does not require any of the above, then the member requires Non-Medical Transportation (NMT).
For more information on Non-Emergency Medical Transportation (NEMT), please review the provider alert below.