This is an in-depth explanation of nursing facility (NF) responsibilities when a Medicare only, private pay or community-based Medicaid recipient applies for the Texas Nursing Facility Medicaid Program after admission to a Texas nursing facility.

  • Communication: It is extremely important that NF staff is aware when a resident and/or his or her representatives intend to apply for the Texas NF Medicaid Program. At admission, anyone who is currently not a recipient of the Texas NF Medicaid Program should be informed which NF staff member they should notify when an application for the Texas NF Medicaid Program is being considered and should be asked to notify the NF staff member as soon as they know the date they intend to apply. The NF staff member who receives this information must ensure that the business office and MDS staff are also aware of the pending application.
  • As soon as the NF facility becomes aware of an application being submitted, NF staff must complete Department of Aging and Disability Services (DADS) Form 3618 and submit it to the Texas Medicaid and Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal. The completion of DADS Form 3618 differs based on the type of admission. When the individual has Medicare and is receiving Skilled Nursing services, Form 3619 is required to admit to Medicare Co-insurance.
    • For residents admitting from private pay, DADS Form 3618 should indicate admission from private pay. The "Date of Above Transaction" will be the first day of the month in which the application was filed. There is a second field in which the physical admission date is indicated. After receipt of DADS Form 3618, be aware that TMHP has an extraction process that automatically selects an MDS for possible use in submitting the Long Term Care Medicaid Information (LTCMI) form. TMHP will extract the MDS in the MDS database that has the closest date to the date on the DADS Form 3618, with or without the "+" in item AA7, as long as the Social Security number (SSN) matches on both forms. Facility staff are ultimately responsible to determine the Omnibus Reconciliation Act (OBRA) MDS for which they want to submit the LTCMI.
    • For residents admitting from Medicare and applying for Medicaid, the DADS Form 3618 "Date of Above Transaction" will be the admission date from Medicare. Payment will not begin until the client also meets Medicaid qualifications, but DADS Form 3618 date should indicate the change in classification from Medicare to Medicaid. The Form 3618 cannot be completed until the client is discharged from Medicare and considered pending Medicaid. After receipt of DADS Form 3618, be aware that TMHP has an extraction process that automatically selects an MDS for possible use in submitting the LTCMI form. TMHP will extract the MDS in the MDS database that has the closest date to the date on the DADS Form 3618, with or without the "+" in item A0700, as long as the SSN matches on both forms. Facility staff is ultimately responsible to determine the OBRA MDS for which they want to submit the LTCMI.
    • For residents admitting from community-based Medicaid into a facility, the DADS Form 3618 "Date of Above Transaction" will be the admission date into the facility (not the first day of the month of the application). Payment will not begin until the client also meets Medicaid qualifications, but the date should indicate the actual admission into the facility. There is no additional extraction for admission from home.
  • As soon as the NF facility becomes aware of an application being submitted, the NF MDS coordinator should:
    • Find the OBRA MDS (A0310A=01,02,03,04,05 or 06) that is not greater than 92 days old that was accepted into the MDS database. Because facilities are not always informed in advance when a Medicaid application is submitted, it is recommended that you select the oldest MDS in the MDS database that is not more than 92 days old. For example, on 6/01/10, there are three OBRA MDS assessments for a resident pending Medicaid – an admission dated 1/24/10, a quarterly dated 4/24/10 and a significant change in status dated 5/27/10. The oldest MDS that is not greater than 92 days old would be the quarterly dated 4/24/10.
    • Modify the selected MDS so that item A0700 contains a "+" in the first box to indicate that Medicaid is pending.
    • Verify that the correct SSN is entered in item A0600A on the MDS. During final processing, the SSN on the MDS must match the SSN certified by Medicaid. If A0600A is incorrect, modify that item on the MDS. A modified MDS must be transmitted to the MDS database.
  • LTCMI submission and Medicaid approval:
    • Once the OBRA MDS and DADS Form 3618 have both been received on the LTC Online Portal, the NF staff responsible for completing the LTCMI form should immediately complete it and submit it on the LTC Online Portal so that the TMHP nurses can begin the medical necessity (MN) determination required as part of the Medicaid application process. Facility staff must monitor the status of the LTCMI after submission to ensure that any requests for additional information are acted upon in a timely manner and for the MN status. If MN is not approved, the Medicaid caseworker for the resident's application is informed and the application is denied. If MN is approved, the Medicaid caseworker continues to evaluate the Medicaid application to ensure that financial and other regulatory requirements are met. If so, the application for the Texas NF Medicaid Program is approved.
    • Any required OBRA MDS completed while Medicaid is pending should contain the "+" in item A0700  (the only exception would be MDS extracted by TMHP without the "+" in A0700) to indicate that Medicaid is still pending and must have an LTCMI submitted to the LTC Online Portal in a timely manner. In the example from item 3, two OBRA MDSs were listed that were not more than 92 days old, one dated 4/24/10 and one dated 5/27/10. If the one dated 4/24/10 was selected, the MDS dated 5/27/10 should also have an LTCMI submitted, as well as any subsequent MDS completed prior to Medicaid approval or disapproval.
    • Once Medicaid for the NF Program is approved, future OBRA MDS assessments should contain the actual Medicaid number in item A0700. In Texas, it is not necessary to go back and correct any prior OBRA MDS that had a "+" to indicate Medicaid pending to replace it with the Medicaid number that is later provided.
    • If Medicaid for the NF Program is NOT approved, future OBRA MDS assessments should contain an "N" in the first block of A0700. In Texas, it is not necessary to go back and correct any prior OBRA MDS that had a "+" to indicate Medicaid pending to replace it with an "N" if Medicaid is later not approved.
  • Any MDS questions regarding these procedures can be directed to the state MDS RAI Coordinator. Any LTCMI or payment questions regarding these procedures can be directed to TMHP at 1-800-626-4117, Option 1.