Massachusetts Nursing Home Medicaid

The clinical review is CAE screening

Massachusetts designates Aging Services Access Points to provide Clinical Assessment and Eligibility, or CAE, screenings for certain MassHealth long-term services and supports, including nursing-facility services for applicants and members age 22 and older. A nursing facility sends the request and necessary clinical documents to the ASAP serving the facility’s city or town (MassHealth ASAP screening guidance).

The state says the ASAP must review and approve the request before MassHealth will pay for the nursing-facility stay. That makes a clinical approval a payment prerequisite, distinct from a completed financial application or a bed offer from the facility (MassHealth ASAP screening guidance).

PASRR is a separate admission safeguard

Massachusetts also uses Preadmission Screening and Resident Review, or PASRR, for every person seeking admission to a Medicaid- or Medicare-certified nursing facility regardless of the payer. PASRR begins with a Level I preadmission screen for serious mental illness or intellectual or developmental disability, with a Level II evaluation when indicated (Massachusetts PASRR guidance).

The Level II evaluation determines whether the person has the identified condition and, when applicable, whether a nursing-facility level of care and specialized services are required. PASRR is not a substitute for MassHealth CAE approval or financial eligibility; it is another required process with a different purpose (Massachusetts PASRR guidance).

Transfers can interrupt payment

A person who otherwise qualifies can still face a period in which MassHealth will not pay for nursing-facility services because of a disqualifying transfer. The regulation applies the 60-month review to post-February 8, 2006 transfers and the state currently lists a $450 daily private-pay nursing-facility cost for the current penalty calculation (130 CMR 520.000; Eligibility Operations Memo 25-16).