Medicaid Eligibility and Preadmission Screening for Mentally Ill and Intellectually Disabled Individuals

PURPOSE: This rule outlines the preadmission screening require ments related to eligibility for Title XIX. PUBLISHER’S NOTE: The secretary of state has determined that publication of the entire text of the material that is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive. This material as incorporated by reference in this rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction. This note applies only to the reference material. The entire text of the rule is printed here. (1) Any individual who is admitted to a Medicaid certified nursing facility (NF) bed on or after January 1, 1989, and has not been screened for mental illness (MI), intellectual disability (ID), or related condition (RC) prior to admission or who does not have a valid special admission category will not be eligible for Title XIX payments to be made on his/her behalf for NF services. (A) The facility must complete a preadmission screening for individuals with a mental illness and individuals with ID as described in 42 Code of Federal Regulations (CFR) 483.20(k). (B) For purposes of this rule an individual is considered to have mental illness if the individual has a serious mental illness as defined in 42 CFR 483.102(b)(1). (C) For purposes of this rule an individual is considered to have an ID if the individual is intellectually disabled as defined in 42 CFR 483.102(b)(3) or is a person with a related condition as described in 42 CFR 435.1010. (2) The requirement for preadmission screening applies whether the individual is a Medicare beneficiary, Medicaid recipient or private pay. (3) Preadmission screening and resident reviews (PASRR) will include an assessment of the individual’s— (A) Physical condition; (B) Mental condition; (C) Need for nursing facility services to comply with 42 CFR 483.112(a); and (D) Need for specialized services for MI, ID, or RC. 1. If a Medicaid nursing facility resident is determined to need specialized services, the state will provide or arrange for such services while the Medicaid participant is in a nursing facility. (4) For purposes of this rule, the term “specialized services” is defined for individuals with— (A) MI as the continuous and aggressive implementation of an individualized plan of care developed and supervised by an interdisciplinary team, which includes a physician, qualified mental health professional and, as appropriate, other professional that prescribes specific therapies and activities for the treatment of persons experiencing an acute episode of MI that necessitates supervision by trained mental health personnel and is directed toward diagnosing and reducing the resident’s behavioral symptoms that necessitated institutionalization, improving his or her level of independent functioning, and achieving a functioning level that permits reduction in the intensity of mental health services to below the level of specialized services at the earliest possible time; and (B) ID or other RC(s) as a continuous program for each client that results in treatment that meets the requirements of 42 CFR 483.440(a)(1) and includes aggressive, consistent implementation of a program of specialized and generic training, treatment, health services, and services that are directed towards the acquisition of the behaviors necessary for the client to function with as much self-determination and independence as possible, and the prevention or deceleration of regression or loss of current optimal function status. Specialized services do not include services to maintain generally independent clients who are able to function with little supervision or in the absence of a continuous treatment program. (5) Medical information needed to do the assessments will be furnished by the attending physician. Other information needed to make the assessments, such as social history and behavior, may be furnished by the individual, guardian, family members, social workers, or other persons. (6) The preadmission screening and resident review process has two (2) parts: Level I and Level II. (A) The purpose of a Level I screening is to identify a nursing facility applicant or resident suspected of having a MI, ID, or RC. (B) The purpose of a Level II evaluation is to perform a comprehensive evaluation in person or by telehealth to validate the applicant has a MI, ID, or RC and evaluate the individual’s treatment needs to determine if NF services are needed and if specialized services are required. If a determination is made that placement in an NF is inappropriate, no Title XIX vendor payments will be made or continue to be made in the case of a resident already in the NF unless the resident meets the requirements of 42 CFR 483.118(c)(1) and elects to stay in the NF. 1. For those individuals already residing or admitted to a NF who experience a change of condition or for those individuals who fall under a special admission category specified in subsection (7)(D), a resident review of the individual’s records in accordance with 42 CFR 483.134 and 483.136 may be required to determine if specialized services are appropriate or if modifications are needed. (7) Any individual identified as having a suspected MI, ID, or RC by the Level I screening will be referred to Department of Mental Health (DMH) for a Level II evaluation. A Level II evaluation is required prior to admittance into a certified bed located in an NF, unless a valid special admission category, as specified in subsection (7)(D), applies. (A) DMH or its designee will perform all Level II evaluations. If a review indicates a level of services that can only be furnished in an intermediate care facility for individuals with intellectual disabilities (ICF/IID), within the Home and Community Based Waiver for the Developmentally Disabled or an acute care mental hospital, that individual is inappropriate for admission or continued stay in an NF. This will be true even if the individual meets the level of care under 19 CSR 3081.030 needed for authorization of Medicaid nursing facility payments. (B) Any individual determined through the Level II evaluation to require specialized services and to not require NF services shall be discharged if the Level II evaluation determines that the individual’s nursing care needs can be met in other settings regardless of the level of care under 19 CSR 30-81.030 unless the resident meets the requirements of 42 CFR 483.118(c) (1) and elects to stay in the NF. 1. If an individual described in subsection (7)(A) has medical needs which can only be met in an NF, as confirmed by and recommended by a Level II evaluation and communicated to the NF by the Department of Health and Senior Services (DHSS), that individual may be admitted or continue to remain in an NF. If the medical condition improves and nursing needs could be met in other settings, the individual shall be discharged unless the resident meets the requirements of 42 CFR 483.118(c)(1) and elects to stay in the NF. 2. A written evaluation report must be prepared at the conclusion of each Level II evaluation. The evaluation report must identify the specific nursing facility services, intellectual disability services, or mental health services required to meet the evaluated individual’s needs. 3. Notice of a decision resulting from a Level II evaluation shall be sent to the referring entity who submitted the Level I screening forms and the proposed placement facility, if different, as well as the evaluated individual and his or her legal representative, the individual’s attending physician, and the discharging hospital unless the hospital discharge is exempt from the preadmission screening per 42 CFR 483.106(b) (2). (C) Any individual admitted to or currently residing in an NF and identified as having a suspected MI, ID, or RC by the Level I screening shall be subject to a Level II evaluation. (D) Special admission categories are subject to advanced group determinations as defined in 42 CFR 483.130(b)(1) and are based on the criteria specified in 42 CFR 483.130(c). 1. The following special admission categories may be admitted directly to an NF after the Level I screening is completed and receive the Level II evaluation or resident review following admission as appropriate based on the individual’s medical condition or admission justification: A. Terminal illness. As defined by the Social Security Act, an individual is terminally ill if there is a medical prognosis that the individual’s life expectancy is six (6) months or less; B. Severely ill. The person is comatose, ventilator dependent, functions at brain stem level, or has a diagnosis of chronic obstructive pulmonary disease, severe Parkinson’s disease, Huntington’s disease, amyotrophic lateral sclerosis, or congestive heart failure that results in a level of physical impairment so severe the individual could not be expected to benefit from specialized services; C. Emergency provisional admission. This category is for a situation in which an individual needs placement to protect the individual from serious physical harm to self or others. The NF must contact DHSS Adult Abuse and Neglect Hotline to make a formal request prior to admission. This special admission category requires prior authorization by DHSS as an emergency. No more than seven (7) days will be allowed for an emergency admission. The Department of Social Services, Family Support Division (FSD), will manage those dates based on information from DHSS. If the individual needs to stay in the NF longer than seven (7) days, the NF must immediately notify DHSS to determine continued stay. A comprehensive Level II evaluation or resident review must be performed after the initial seven- (7-) day period if continued stay is necessary; D. Respite care. An individual may be admitted and remain in an NF for thirty (30) consecutive days or less with a forty-two- (42-) day maximum in twelve (12) months in order to provide respite for the individual’s caregiver. A comprehensive Level II evaluation is not required for the first thirty (30) consecutive days. FSD will control the NF authorized payment dates by means of a form they send to DHSS. No payment will be made to the NF beyond the thirty (30) days. If a situation arises in which the stay is longer than thirty (30) days, the NF must contact DHSS. If a continued stay is authorized, a comprehensive Level II evaluation or resident review must be performed within forty (40) calendar days of the individual’s admission to the NF if continued stay is necessary; and E. Direct transfer from a hospital. If a physician attests that the individual is likely to need thirty (30) days or less of NF care for the condition for which the individual was hospitalized, the individual may be admitted to an NF and no Level II evaluation or resident review is required during that thirty (30) days or less period. NF payment will be made for no more than thirty (30) days. If after admission to the NF it becomes apparent that the individual will need NF care longer than thirty (30) days, the NF must immediately notify DHSS. If a continued stay is approved, a comprehensive Level II evaluation must be performed within forty (40) calendar days of the individual’s admission to the NF. (8) The Department of Social Services, DHSS, and DMH will have joint responsibility for the preadmission screening process. (9) This rule incorporates by reference the following materials, as published by U.S. Government Publishing Office, U.S. Superintendent of Documents, Washington, DC 20402, October 1, 2023. This rule does not incorporate any subsequent amendments or additions: (A) 42 CFR section 483.20(k); (B) 42 CFR section 483.102(b)(1); (C) 42 CFR section 483.102(b)(3); (D) 42 CFR section 435.1010; (E) 42 CFR section 483.112(a); (F) 42 CFR section 483.440(a)(1); (G) 42 CFR section 483.118(c)(1); (H) 42 CFR section 483.134; (I) 42 CFR section 483.136; (J) 42 CFR section 483.106(b)(2); (K) 42 CFR section 483.130(b)(1); and (L) 42 CFR section 483.130(c). AUTHORITY: section 208.201, RSMo 2016, and section 208.153, RSMo Supp. 2025.* Emergency rule filed Dec. 30, 1988, effective Jan. 10, 1989, expired April 29, 1989. Original rule filed Feb. 15, 1989, effective April 27, 1989. Amended: Filed June 6, 1989, effective Aug. 24, 1989. Amended: Filed July 23, 1991, effective Dec. 9, 1991. Amended: Filed May 27, 1999, effective Jan. 30, 2000. Amended: Filed Nov. 14, 2025, effective May 30, 2026. *Original authority: 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007, 2012, 2024, and 208.201, RSMo 1987, amended 2007.