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Changes Coming to the Michigan Medicaid Nursing Facility Level of Care Determination Process

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Changes Coming to the Michigan Medicaid Nursing Facility Level of Care Determination Process

The Michigan Medicaid program is proposing to modify its Nursing Facility Level of Care Determination (LOCD) effective November 1, 2018. See Proposed Policy 1819-LOCD—Level of Care Determination (LOCD) Process Improvements. The Nursing Facility LOCD is used to determine an individual’s eligibility for a variety of Medicaid long-term care benefits: nursing facility care, MI Choice Waiver programs, Program of All-Inclusive Care for the Elderly (PACE), and MI Health Link. It determines whether an individual meets the medical/functional criteria for Medicaid payment for these services. Providers that do not properly complete a LOCD when needed may not bill the Medicaid program for services provided to the applicable individual, and are subject to retroactive recoupment of payments received and potential False Claims Act allegations.

The principle proposed modifications to the LOCD are:

  • Expansion of individuals who can perform the LOCD: Under the proposal, any of the following licensed health professionals affiliated with the applicable provider may conduct the LOCD—physician, registered nurse, licensed practical nurse, clinical social worker (Limited License Bachelor of Social Work [LLBSW], Limited License Master Social Worker [LLMSW], Licensed Bachelor Social Worker [LBSW], or Licensed Master Social Worker [LMSW]), physician’s assistant, physical therapist, respiratory therapist, occupational therapist or speech therapist. A non-clinical individual may upload the data into CHAMPS. All LOCDs must be uploaded into CHAMPS in order to be valid and support Medicaid billing.
  • Timing of the LOCD: The proposal would permit providers to conduct LOCDs and upload them into CHAMPS for individuals who are not yet Medicaid beneficiaries or Medicaid pending. This is a significant change from current policy and should make it simpler for providers to be certain that LOCDs are in place by the time that individuals are ready to use Medicaid benefits. In addition, a LOCD will remain valid for 365 days after it is conducted and uploaded into CHAMPS. All LOCDs must be uploaded into CHAMPS within 14 days after they are conducted.
  • LOCD follows the person: In another significant change, the proposed policy would permit the LOCD to be associated with the individual, rather than the facility or service provider in which the individual is admitted or enrolled. This means that a new provider to which an individual is transferred would no longer need to conduct a new LOCD so long as the individual has a valid LOCD already in CHAMPS. The onus is upon the new provider to verify the accuracy and effective date of the old LOCD before relying upon it. A provider with concerns about an existing LOCD should perform a new one in order to protect their right to bill Medicaid.
  • Freedom of Choice forms: Regardless of whether a new LOCD must be conducted under the proposed policy, an individual must sign a new Freedom of Choice (FOC) form before entering any program for which a LOCD is required. This ensures that individuals have timely and complete information about all the available Medicaid options to meet their needs.
  • Retroactive Medicaid eligibility: Under the proposed policy, CHAMPS would no longer automatically reimburse nursing facilities for up to 114 days prior to the date the LOCD was uploaded into CHAMPS to account for retroactive Medicaid eligibility. Providers seeking retroactive reimbursement must contact MDHHS Provider Support to request a change to the LOCD record.
  • Nursing Facility CHOWS: New owners receiving a new National Provider Identifier (NPI) during a CHOW must prepare a hard copy version of the LOCD and FOC pending full access to CHAMPS under its new NPI. The new owner must then upload all the information from the hard copy LOCD into CHAMPS under its new NPI. To ensure proper payment, CHAMPS will then check if the conducted date of the LOCD and enrollment date of the new NPI are within the last six months. Per the proposed policy, both conditions must be met during a CHOW for CHAMPS to process payments.

Comments on the proposed policy will be accepted until August 22, 2018. Comments should be sent to: L. Alisyn Daniel-Crawford, Esq., MPH, Bureau of Medicaid Policy and Health System Innovation, Medical Services Administration, P.O. Box 30479, Lansing, MI 48909 or daniell@michigan.gov.

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