Wisconsin Department of Health Services
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Preadmission for Nursing Homes. New Requirements Effective July 1, 2009The purpose of this memo is to present guidance to nursing homes about their responsibility to make referrals on behalf of and to provide information to prospective residents. The information and referral requirements are often referred to as Preadmission Consultation (PAC) requirements. The Preadmission Consultation requirements go into effect on July 1, 2009. Part I of this Memo provides background information on the necessity of the referral and information dissemination; Part II outlines the preadmission requirements for providers; and Part III provides information on the current status of each county. Part I: BACKGROUND With the enactment of 2007 Wis. Act 20 in October 2007, new pre-admission consultation (PAC) requirements came into effect as a part of the statewide transition to new publicly funded long-term care programs available to individuals who are eligible for Medicaid in Wisconsin. These programs include the IRIS (self-directed supports waiver) program and managed long-term care programs. Currently, two programs are managing long-term care in Wisconsin - Family Care and the Partnership. More information on Family Care and Partnership is available at: http://dhs.wisconsin.gov/LTCare/. IRIS information can be found at: http://dhs.wisconsin.gov/bdds/iris/. As of June 1, 2009, 37 of Wisconsin's 72 counties will have Managed Care/IRIS. The new requirements affect facilities in those counties with Managed Care/IRIS and in counties where Medicaid Waiver programs are available. When managed care is made available in a county, new PAC requirements take effect. Before implementing a Managed Care Organization (MCO) in a county, an Aging and Disability Resource Center (ADRC) will open to serve the community. ADRCs are a resource for individuals aged 65 and over as well as individuals with physical or developmental disabilities. The ADRC in Milwaukee County serves individuals aged 60 and older. An ADRC's primary functions are to provide information and assistance, offer long-term care options counseling, determine eligibility for publicly funded long-term care, and enroll individuals in the program they select, as appropriate. Until an MCO begins to operate in a particular county, the current waiver system will remain in effect. Nursing homes play an important role in directing citizens to the ADRCs or the appropriate (existing) county program. Facilities may be required to complete and submit a referral form on behalf of the prospective resident. The required referral form (DQA form F-62493) with instructions is available online at: http://dhs.wisconsin.gov/forms/DQAnum.asp. Facilities may also be required to offer information to prospective residents and/or their families as to the availability of an area ADRC. Certain prospective residents are exempt from the referral requirement. Facilities are not required to refer:
Part II: REQUIREMENTS FOR PROVIDERS Providers' responsibilities change when managed care becomes available in a county. DQA is responsible for monitoring compliance with the application of state statutes, regardless of the presence of an MCO. Providers that are found not complying with the regulations may be subject to citation and forfeiture. All nursing homes are subject to the requirements set forth in Wis. Stat. subch. I, ch. 50, whether or not they are part of the MCO network of providers. The Secretary of the Department is responsible for certifying that the ADRC is available to individuals seeking admission to a facility. Because ADRCs may choose to phase in their services and eligible groups, DQA will begin to monitor for the new requirements when an MCO begins operation. The MCO start dates will be available through the DQA Publications on the DQA Listserv. To sign up to receive DQA Publications, go to: http://dhs.wisconsin.gov/rl_DSL/Listserv/signup.HTM Nursing Homes Before managed care/IRIS is available: No requirements. After managed care/IRIS is available: Wis. Stat. § 50.04(2g) and Wis. Admin. Code § DHS 10.73(3), require nursing homes operating in a county with a certified ADRC to provide information about the ADRC to prospective residents when they first provide written information about their facility. Facilities are required to provide a copy of the brochure, "Considering Assisted Living or a Nursing Home: What You Should Know", to prospective residents and/or their families as to the availability and services of the ADRC. The brochure is available on line at: http://dhs.wisconsin.gov/LTCare/Generalinfo/PAC.htm. Wis. Stat. § 50.04(2h) and Wis. Admin. Code § DHS 10.73(4), require nursing homes operating in a county with a certified ADRC to complete a Referral for Pre-Admission Consultation form (DQA form F-62493) for individuals, with certain exceptions, who are 65 years of age or older or who have a developmental or physical disability expected to last at least 90 days. The referral is to be sent to the ADRC in the county where the prospective resident currently resides. The referral form and instructions are available online at: http://dhs.wisconsin.gov/forms/DQAnum.asp. Section I of the referral form is to be completed by facility staff. Sections II and III of the referral form are to be completed by the prospective resident or his or her representative. Facility staff may be asked by the individual to answer questions about the form or to provide assistance. If the prospective resident or the representative answers "yes" or "not sure" to the question on the form about the opportunity to talk with someone from the ADRC (question 4), staff from the ADRC should contact the individual by telephone within 5 business days after receiving the referral, as indicated in DLTC Numbered Memo Series 2009 - 07, to offer information about services available in the community. Facilities may admit the prospective resident to the facility prior to the contact from the ADRC; or, the prospective resident may choose to wait until he or she has had the opportunity to meet with the ADRC before proceeding with admission. If the prospective resident or representative answers "no" to question 4, they will not be contacted by the ADRC. In cases where the prospective resident has indicated that they wish to "opt out" of the ADRC follow up contact; facilities must still submit the referral to the ADRC. If the prospective resident or representative declines to complete or sign the form, the facility should fill in the name, address and telephone number of the prospective resident, if known, and submit the referral form to the ADRC. The facility should indicate the individual declined to complete and or sign the form as specified in the "for facility use only" instructions for the form. Providers are required to send the completed referral form to the ADRC no later than the close of the next business day after facility staff first provides an assessment of the person's needs for nursing or residential services or at the time that it accepts an application for admission from the person. The facility shall retain a copy of the referral for their files. Note: There may be situations where the prospective resident's county of residence does not have managed care and or an operating ADRC. In those situations, the referral is to be sent to the county human services department in the county where the prospective resident resides. ADRC contacts can be accessed at: http://dhs.wisconsin.gov/LTCare/Generalinfo/rcs.htm. For County contacts, please go to: http://dhs.wisconsin.gov/LTC_COP/CONTACTS.HTM. The facility is not required to complete and submit a Referral for Pre-Admission Consultation form if:
The facility is required to provide and/or send a copy of the brochure, "Considering Assisted Living or a Nursing Home: What You Should Know", to the prospective resident or their representative informing them about the availability and services of the ADRC. The brochure is available on line at: http://dhs.wisconsin.gov/LTCare/Generalinfo/PAC.htm. DQA staff will monitor for compliance with these requirements during survey. Failure to comply with these requirements may result in a citation and forfeiture of up to $500 for each violation. See Wis. Stat. § 50.04(5)(a)3. Part III: COUNTY STATUS Counties in which an MCO currently operates:
* Effective July 1, 2009 these counties will have a Managed Care Organization (MCO). If you operate a nursing home in one of the aforementioned counties, you are responsible for meeting the requirements to provide information to prospective residents and to complete a referral form on their behalf.
The MCO start dates will be available through the DQA Publications on the DQA Listserv. To sign up to receive DQA Publications, go to: http://dhs.wisconsin.gov/rl_DSL/Listserv/signup.HTM. The requirement to provide information takes effect when an MCO begins to operate in your county. If you have any questions about this memo, please contact the appropriate Regional Field Operations Director for the region in which your facility is located.
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