Medical necessity and level of care
DHS policy says functional-need decisions for nursing-facility applicants and recipients are made by the Division of Provider Services and Quality Assurance Office of Long-Term Care. The medical-necessity decision is sent on DHS-0704, Evaluation of Medical Need Criteria, which classifies the patient for a level of care (DHS Medical Services Policy Manual, F-151 and H-440).
Applicants with indicators or diagnoses of intellectual disability or mental illness may need Pre-Admission Screening and Annual Resident Review, or PASARR, before nursing-facility entry. DHS policy says a person subject to that process is not eligible for nursing-facility reimbursement before the relevant PASARR determination date unless an emergency admission has been prior authorized (DHS Medical Services Policy Manual, F-151).
Personal-needs allowance and cost of care
DHS's published manual directs workers to subtract a $40 personal-needs allowance for most facility residents. A resident whose only income is SSI keeps $30, while a single veteran or veteran's spouse with no dependents whose VA pension has been reduced to $90 receives that $90 as the allowance rather than an additional $40 (DHS Medical Services Policy Manual, H-410).
The same policy excludes VA Aid and Attendance payments and certain VA medical-expense reimbursements from income for the cost-of-care calculation. It separately says income put in a qualifying income trust remains countable toward patient liability even though it is not countable for initial eligibility (DHS Medical Services Policy Manual, E-451 and H-111).
Dates can change payment
DHS identifies date of entry, date of medical necessity, and date of categorical eligibility as the three factors for nursing-home and ICF/IID service eligibility. Authorization cannot begin until all three have been satisfied (DHS Medical Services Policy Manual, H-440).
Most residents' PNA: $40/month.
Medical-need decision: OLTC/DPSQA using DHS-0704.
Additional screening: PASARR where the policy requires it (
DHS Medical Services Policy Manual).
Prepare for both financial and clinical review
Keep facility admission paperwork, the DHS-0703 and DHS-0704 process information, income documentation, resource records, and transfer records together. Financial approval and a medical-need decision are related but distinct parts of the nursing-facility pathway.
Not mutually exclusive. Most families combine two or three funding pillars — this one rarely stands alone.
The
Journey Assessment ranks all ten pillars against your specific situation and
recommends the top three.
