Nf: Eligibility

The Department determines whether a participant meets criteria for NF services, any patient liability and whether a participant's needs can be met in alternative living situations other than residing in a NF. The participant can select any certified NF to provide the level of care (LOC) required, if approved. (7-1-26) 01. Determination. The Department determines a participant’s level of care requirement and any need for DD or mental illness (MI) active treatment during the Level II screen. (7-1-26) a. Adult LOC. The Department uses a standard assessment to determine adults meet one (1) of the PDPM classifications. (7-1-26) b. Children’s LOC. A child meets LOC when the age-appropriate developmental milestones, risk factors, and aggregate care or intervention needs identified in assessments indicate one (1) or more of the following applies as documented by physician's orders, progress notes, a service plan, and nursing or therapy notes: (7-1-26) i. A complex provider prescribed service that requires skills of an RN or licensed physical or occupational therapist or only under equivalent supervision for safe and effective delivery. (7-1-26) ii. The child's condition requires skilled care to sustain current capacities, regardless of their restoration potential, even when improvement is not possible. (7-1-26) 02. Authorization. The Department does not authorize payment to any NF for care or services beyond the NF's licensed level of care or capability. The Department notifies the NF with the authorized payment for services and any patient liability prior to admission. (7-1-26)