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OBRA

Page posted: 10/01/03

Page reviewed:

Page updated: 06/24/10

Legal Authority

42 C.F.R. 483, subpart C, 483.100 – 483.138, Minn. Stat. §256B.0911 (LTCC), Minn. Stat. §256B.092 subd. 7, 8 and 8a (Rule 185 CM)

Definition

Omnibus Budget Reconciliation Act (OBRA) 1987: Federal law that mandates the screening and review of all persons with a diagnosis or suspected diagnosis of developmental disability who seek admission to a nursing facility regardless of the source of payment for the NF services.

Note: Federal language uses the term developmental disability. Where referenced, this page will use the term developmental disability.

Background

The Omnibus Budget Reconciliation Act 1987 requires states to determine the appropriateness of MA-certified NF placement for persons with mental illness or developmental disabilities.

Minnesota legislation expanded preadmission screening (PAS) activities to all persons that apply for admission to NFs certified by MA. In 2001, the Minnesota Legislature incorporated Minnesota guidelines regarding admission decisions for persons seeking services in a NF and county concurrence into the Long Term Care Consultation services.

PAS determines the need of a NF level of care. PAS activities also consist of:

  • • Level I Screening to identify all persons who might have a diagnosis of developmental disability
  • • Level II Evaluative Report to evaluate and determine if NF services and specialized services (active treatment) are needed if indicated by Level I Screening
  • Specialized Services (Level II)

    For persons who have a diagnosis of developmental disability, specialized services are the services specified in the Individual Service Plan that, when combined with services provided by the NF, result in treatment that meets the requirements in 42 C.F.R. 483.440 Active Treatment Services.

    All NF residents who have primary or secondary diagnosis of developmental disability whose needs are such that continuous supervision, treatment and training by a qualified developmental disability professional is necessary must receive specialized services.

    The evaluation and determination of the need for specialized services, when using the categorical determinations to determine NF needs, must be completed by a QDDP.

    Throughout this page, specialized services and active treatment are used interchangeably.

    OBRA Responsibilities

    The DD screening team is responsible to:

    1. Review all needs of the person.
    2. Confirm person needs the level of services provided by the NF.
    3. Confirm diagnosis of developmental disability.
    4. Assess if the person needs active treatment.
    5. Determine how active treatment will be delivered and funded.
    6. Document consultation/screening team activities in MMIS.
    7. Submit MMIS documents for DHS approval.
    8. Monitor NF placement at least annually for continued appropriateness of placement.

    Screening Exceptions

    NOTE: OBRA exemptions do not apply to persons age 20 years or younger.

    Exempted hospital discharge (Does not apply to persons on the DD Waiver)

    A person age 21 years or older, with any diagnosis, may be exempt from the screening process when all of the following criteria are met:

  • • Person is admitted to a NF directly from an acute care hospital admission
  • • Person requires NF services for the same condition hospital services were provided
  • • Attending physician certifies the person will need NF services for less than 30 days before NF admission
  • NOTE: If the NF stay exceeds 30 days, a preadmission screening, level I determination, level II evaluation and full-team screening must be conducted within 40 days of the admission.

    Interfacility transfers and re-admissions

    A person age 21 years or older with or without a diagnosis of developmental disability is exempt from OBRA activities related to NF admissions when the person:

  • • Returns to a certified Minnesota NF after having entered an acute care facility from a certified NF in Minnesota (except for psychiatric admission)
  • • Transfers from one certified NF in Minnesota to another certified NF in Minnesota without returning to the community.
  • BI, CAC, CADI and Elderly Waiver respite

    Specialized service needs do not have to be assessed when NF admissions are based on county contracted respite stay as a waiver service.

    Forms

    Counties must use forms and criteria developed by DHS to identify persons who require referral for further evaluation and determination of the need for specialized services.

    Evaluative Report: Level II Preadmission Screening for Persons with Developmental disability DHS-4248 (PDF)
    LTCC Services and Assessment Form DHS- 3428 (PDF)

    Preadmission and Screening Assessment Program: Level I Screening for Mental Illness or Developmental disability DHS-3426 (PDF)
    Related Conditions Check List/Instructions DHS-3848 (PDF)

    Additional Resources

    Adult Mental Health PASRR and Level I and II Screenings Bulletin (For information on OBRA for persons who have mental illness and seek admission to a NF)
    DD Screening Document DHS-3067 (PDF)

    DD Screening Document Codebook
    Level II Preadmission Screening Process Flowchart for persons KNOWN to county or open on DD caseload (PDF)

    Level II Preadmission Screening Process flowchart for persons NOT KNOWN to county or open on DD caseload (PDF)

    Nursing Facility Level of Care DHS-3361 (PDF)

    Screening Forms

    Process and Procedure

    Out of state services
    Assessment / OBRA Process

    MMIS & Billing

    Reassessment / Annual Monitoring

    Out-of-state services

    Out-of-state services

    If the person does not meet the 30-day exemption, the county must perform PAS (including OBRA level I and OBRA level II evaluations) for all Minnesota residents seeking NF admission to an out-of-state facility funded by Minnesota Medical Assistance.

    For persons seeking admission to NFs located outside of Minnesota when the admission is not paid for by Minnesota Medical Assistance, admission activities must be guided by the rules in the state in which placement is being sought.

    People being admitted to Minnesota NFs from other states should have their preadmission screenings performed by the state from which they come when that state is paying for the stay.

    Assessment / OBRA Process

    Level I Evaluation

    1. Determine the need for NF level of care.
    2. Evaluate whether a DD diagnosis condition is present or suspected.
    3. Refer for a Level II evaluation to the county of financial responsibility if developmental disability is present or suspected. In the case of private pay, refer to the county in which the facility is located.

    Level II Evaluation

    1. Conduct a full team screening within seven to nine working days of receiving the Level I referral from the PAS team.
    2. If the person is unknown to the county, refer the individual for a psychological evaluation to verify if a developmental disability exists.
    3. Confirm the need for NF care.
    4. If found to have a diagnosis of developmental disability, determine if active treatment is needed during the NF stay. The evaluation and determination of the need for specialized services must be made by a QDDP.
    5. Enter the full team screening and level II information in MMIS and route to location 570.

    Keep a copy of the Level I and Level II forms in the person’s lead agency case file and forward a copy of each to the NF.

    When a person is transferred from a NF to a hospital or another NF, the transferring NF is responsible to send copies of the most recent Level II evaluative report along with the person.

    MMIS & Billing

    Screening documents with incomplete information will not be approved. NFs cannot bill MMIS for services without an approved MMIS screening document. DHS reviewers will approve the document in MMIS and note any communication to the screening teams via the DHS comments page.

    Contact DHS if the information cannot be entered into MMIS within the required timelines.

    MMIS documentation

    1. Enter a full team screening document (01) in MMIS.
    2. Enter Level II evaluation information on the case manager comment screen. All of the following documentation must be provided in order for the document to be approved. DHS form 4248, the Level II Evaluative Report, may be used as the template for this documentation.

    Level II information must include:

  • • Agreement of appropriateness of NF placement
  • • Agreement or disagreement of finding or history of developmental disability
  • • Date of NF admission
  • • Date of screening
  • • Method of providing and funding active treatment when recommended
  • • Need for active treatment
  • • Projected date of NF discharge
  • DD Waiver

    For people who were on the DD Waiver prior to admission to the NF, the waiver out date must be the same or earlier than the date of NF admission.

  • • Change the header end date of the DD Waiver Service Agreement to the same as the waiver out date
  • • Change the end date of Service Agreement line items to the waiver out date or earlier
  • Reassessment/Annual Monitoring

    Federal regulations require that persons with a diagnosis of developmental disability who reside in NFs receive a review of the continued appropriateness of their NF stay and the need for active treatment services not less than annually.

    Counties may document this information in a number of ways, depending on other screening requirements for the individual. For any person with a developmental disability diagnosis, a county may elect to perform an annual full-team screening and enter the information as a 01 screening document in MMIS.

    Persons who receive Rule 185 case management services

  • • Perform an annual full-team screening and enter the information as an 01 screening document in MMIS or
  • • Use the annual update (02) screening document
  • Persons not receiving Rule 185 case management services

  • • Perform an annual full-team screening and enter the information as an 01 screening document in MMIS or
  • • Use the annual LTCC NF visit
  • Persons who declined both Rule 185 case management and annual LTCC visits or aged out of the LTCC annual visit requirement

  • • Perform a full-team screening every three years and enter the information as an 01 screening document in MMIS or
  • • Use the annual update (02) screening document every two years
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