2240 Level of Care | Medicaid

Georgia Division of Family and Children Services
Medicaid Policy Manual

Policy Title:

Level of Care

Effective Date:

February 2020

Chapter:

2200

Policy Number:

2240

Previous Policy Number(s):

MT 49

Updated or Reviewed in MT:

MT-58

Requirements

An approved level of care (LOC) is a basic eligibility requirement for the following ABD Medicaid classes of assistance (COAs):

Institutionalized Hospice Care
Community Care Services Program (CCSP)
TEFRA/Katie Beckett
Hospice Care
Hospital
Independent Care Waiver Program (ICWP)
Nursing Home
New Options Waiver (NOW)
Comprehensive Supports Waiver Program (COMP)
Swing Beds

Basic Considerations

The Alliant Health Solutions (AHS) or other DMA approved entities determine the LOC for the above mentioned COAs.

For ABD Medicaid eligibility, LOC is defined as nursing facility care and is verified by receipt of an approved instrument indicating that the A/R meets the LOC requirement for that COA. The distinction between different levels of care is not relevant for Medicaid eligibility purposes.

In some instances, a LOC may only be approved for a limited period of time. Refer to 2577 Limited Stays for procedures for a limited stay.

If a LOC is not approved, DMA is notified by the agency responsible for the decision. DMA then notifies DFCS of non-approval by letter. DFCS cannot approve Medicaid under a Medicaid Cap COA but must review eligibility under other COAs.

Procedures

Use the following chart to determine how to obtain verification of LOC for each class of assistance:

Chart 2240.1 – Verifying Level of Care

IF A/R is

THEN verify LOC by

in CCSP

The LOC form, CCSP Level of Care and Placement Instrument, approved by the CCSP RN care coordinator.

The physician and RN care coordinator complete the LOC form.
The RN care coordinator can approve a LOC for a CCSP stay of up to one year. The stay begins on the day the LOC form is signed by the RN care coordinator.
If the RN care coordinator approves a LOC, the approved LOC form is sent to DFCS.
The RN care coordinator redetermines the LOC before the expiration date on the current LOC form. If approved for a new LOC, the care coordination agency sends a copy of the new LOC form to DFCS.

If the LOC form is not sent to DFCS within 30 days of the application date, follow up with the Care Coordinator by phone and in writing on the Community Care Communicator.

in hospice care at home or nursing home

receipt of a Hospice Care Communicator stating a prognosis of six months or less life expectancy.

Form DMA-6 is not required.

in a hospital

written or telephone contact with the hospital.

Form DMA-6 is not required.

in ICWP

A LOC instrument via AHS obtained from the ICWP case manager.

in NOW/COMP

An approved LOC instrument completed by a vendor approved by Mental Health for approval of any level of nursing facility care. Obtain a copy of the approved LOC instrument from the NOW/COMP CET. If a gap in days occurs between LOC instruments, a “Level of Care Agreement” form signed by a physician is an acceptable LOC instrument for the gap in days.

in NH or hospital with an IC-MR LOC

An approved DMA-6 or DMA-6(A) completed by a vendor authorized by Mental Health for approval of the IC-MR LOC. The county should be mailed a copy of the DMA-6 or 6(A). At a minimum the DMA-6 should show a signature and date in box 37 and a payment date and paid through date just above the signature in box 37. A “stamped” LOC on the 6 is not necessary.

Parkwood of Augusta’s LOC will continue to be completed by GMCF.

in a nursing home

Form DMA-59, Authorization of Nursing Facility Reimbursement, from the nursing home, signed by administrator.

Form DMA-6 is completed by the physician and the Director of Nursing at the nursing home and remains on file at the NH. No copy of Form DMA-6 is sent to DFCS for admissions after 4/1/03.

A new Form DMA – 59 should be received at each new readmission, even if from a different COA while in the NH (such as Institutionalized Hospice to NH).

If the Form DMA-59 is not received within 30 days of the application date, follow up by phone and in writing on Form 950, Facility Action Request.

Prior to 4/1/03, LOC approval requires a Form DMA-6 from GMCF.

If the NH is under a Medicaid sanction resulting in a “ban on admissions”, refer to Section 2141-2, “Nursing Home”.

in a swing bed

An approved LOC instrument from AHS showing a skilled or intermediate LOC approval. For question regarding a pending LOC for a Swing Bed A/R, call the CIC at 800-766-4456, select option 6, then option 1, then option 4.

in Katie Beckett or GAPP COA

Form DMA-6(A) approved by AHS for any level of nursing facility care. If the LOC is approved, AHS issues a LOC approval letter for a specified period of time. LOC approval may range from 90 days or up to a year unless the LOC approval indicates otherwise. For questions regarding a pending LOC contact your Medicaid Program Specialist.

See 2133 TEFRA/Katie Beckett for specifics on procedures for obtaining an approved LOC. See 2933 Georgia Pediatric Program for referral to GAPP.

Use the following chart to determine the actions to be taken after a LOC determination has been made.

Chart 2240.2 – Action after a LOC Determination

IF the Approving Agency

THEN

approves a LOC and sends an approved LOC instrument to the county DFCS

approve Medicaid under the appropriate COA upon completion of the eligibility determination.

Refer to 2551 Patient Liability/Cost Share Overview and 2576 Vendor Payment Authorization for instructions on the patient liability/cost share determination and vendor payment authorization.

approves a LOC for a limited stay and sends an approved LOC instrument to the county DFCS indicating a specified number of days

approve Medicaid under the appropriate COA upon completion of the eligibility determination.

Refer to 2551 Patient Liability/Cost Share Overview for instructions on the patient liability/cost share determination. Authorize services only for the period of time indicated on Form DMA-6 or approved LOC instrument. Refer to 2577 Limited Stays.

NH residents are no longer approved for Limited Stays effective 4/1/03. All NH stays are considered permanent until notified by the NH or other entity of discharge, ineligibility or death.

does not approve a LOC and DMA notifies the county DFCS by letter

do not approve Medicaid under a Medicaid CAP COA. Complete a Continuing Medicaid Determination to review eligibility under all other COAs. Refer to 2052 Continuing Medicaid Determination.

Effective July 1, 2003, the following vendors are authorized to perform Level of Care (LOC) authorization for the IC-MR LOC and for the NOW/COMP COAs.

West Central Region
*Columbus Community Services
1501 13^th Street, Suite E
Columbus, Ga. 31901
Phone: 706-494-5929
Fax: 706-494-5931
Emergency: 706-536-1545
ccswcentral@aol.com

East Central Region
*Columbus Community Services
1058 Claussen Road, Suite 108
Augusta, Ga. 30907
Phone: 706-736-0401
Fax: 706-736-0403
Emergency: 706-951-8372 or 678-592-4172
ccsecentral@aol.com

North Region
North Intake and Evaluation Team
475 Tribble Gap Road, Suite 120
Cumming, Ga. 30040
Phone: 770-886-3407
Emergency: 678-852-4302
Fax: 770-886-8540

Southeast Region
Southeast Intake and Evaluation Team
MHDDAD Regional Office
7001 Chatham Center Drive
The Liberty Building, Suite 600
Savannah, Georgia 31405
Phone: 912-651-0964
Fax: 915-651-0968
Toll Free: 800-348-3503

Central Region
Central Intake and Evaluation
Central State Hospital
Yarbrough Building, Room 3068
Milledgeville, Ga. 31062
Phone: 478-445-7735
Fax: 478-445-7121
Emergency: Karla Brown-478-731-4970
KBBROWN8@dhr.state.ga.us

Metro Region
*Columbus Community Services
2300 Henderson Mill Road, Suite 100
Atlanta, Ga. 30345
Phone: 770-938-5310 (24 hrs.)
Fax: 770-938-7815

Southwest Region
*Columbus Community Services
235 Roosevelt Ave., Suite 251
Albany, Ga. 31701-2372
Phone: 229-435-3212
Fax: 229-435-3262
Emergency: 229-291-3587

Parkwood of Augusta’s LOC determinations will continue to be done by GMCF.

*All Columbus Community Services offices can be reached through Toll Free Number: 800-579-7609 or www.columbuscommunityservices.com/ccs/home.jsp

GMCF Address:
GMCF
1455 Lincoln Pkwy, E.
Suite 750
Atlanta, Ga. 30346-2209

or Fax: 678-527-3547