To be eligible for services applicants must meet both income and resource limits, which may be higher than the limits for other Medicaid programs. Other criteria considered include functional status, age, citizenship, medical needs and Georgia residency. Medicaid Waiver programs also require that applicants qualify for the level of care provided in a nursing facility or other qualified institution.

Hospice

Provides for Medicaid members as a public agency, private organization or a subdivision of either that is primarily engaged in care to terminally ill individuals with a physician’s prognosis of six months or less to live. Hospice services are forms of palliative medical care designed to meet the physical, social, psychological, emotional, and spiritual needs of terminally ill individuals and their families.

Hospice care may include:

• Nursing, physician, social and counseling services, short-term inpatient care, medical appliances and supplies, physical therapy, occupational therapy and speech-language pathology services. 
• Services in the individual's home or within a long- term care facility such as a nursing home and is considered the residence of the individual.
• Managing a patient’s pain and other symptoms so that the individual may live as comfortable as possible.

The focus of hospice services is palliative care rather than curative care. Children and youth up to the age of twenty-one can receive “Concurrent care” when electing hospice; which means they may receive curative treatment as well as palliative care. This enables Georgia to make hospice services available to children eligible for Medicaid and Medicaid CHIP programs without forgoing any other treatment to which the child or youth is entitled under Medicaid. Hospice services and supports to children continue to include pain and symptom management and family counseling provided by specialty-trained hospice staff. When an individual elect’s hospice care a plan of care must be established before services are provided. To be covered, services must be rendered consistent with the plan of care. When multiple providers are involved in care, the Hospice provider remains the coordinator of all care received by the Medicaid member.

Levels of Hospice care:

• Routine Home Care - Includes nursing and home health aide services.
• Continuous Home Care - When a patient needs continuous nursing care during a time of crisis.
• Inpatient Respite Care - Short-term care intended to relieve family members or others caring for individual.
• General Inpatient Care - Short-term care during times when pain and symptoms cannot be managed without a hospital setting.

For more information, please review the policy manual here.

Nursing Homes

When Nursing Facility Residents indicate a preference to live in the community - Click here for Georgia’s Aging and Disability Resource Connection

Pre-Admission Screening and Resident Review (PASRR)

• Pre-Admission Screening and Resident Review (PASRR) is completed for all nursing home residents including hospice and private pay applicants prior to admission and/or for any status change to determine if there are indicators of mental illness and/or Intellectual Developmental Disabilities. This screening is intended to assess whether an individual is appropriate for a nursing facility placement. Screening occurs prior to admission or when there is a significant change in the physical or mental condition of a resident (resident review or RR). All nursing facilities must ensure that a person does not require a Level II screening before any applicant is admitted to a nursing facility. 
•  Federal regulations (42CFR483.100-138, Subpart C) require that all individuals applying for or residing in a Medicaid-certified nursing facility be screened to determine whether they:

1.  Federal regulations (42CFR483.100-138, Subpart C) require that all individuals applying for or residing in a Medicaid-certified nursing facility be screened to determine whether they:
2.  Require the level of services provided by a nursing facility; and if so
3.  Require specialized services beyond what the nursing facility may provide.

• The completion of the Level I/Level II screening process is mandatory to receive the issued Prior Authorization (PA) number which is entered on claims for Medicaid reimbursement.  The Level I screening which is completed by Alliant Health Solutions, is the first step to determine if there are positive indicators for a mental health diagnosis or suspected diagnosis. Those who do not meet the criteria for the Level I screening are referred to Beacon Health Options for a Level II assessment. The Level II assessment determines if a nursing facility level of care is appropriate and if the individual requires additional mental health or other specialized services during their nursing facility residency.

PRIOR AUTHORIZATION (PA) requirements for Nursing Facilities

• Prior Authorization are required for all Nursing Facility Claims. PAs are generated by submission of the Pre-Admission Screen. Please find below links for information on the processes for PASRR Level I and Level II:
  • PASRR Provider Training Combined - Posted 8/18/18
  • PASRR Trifold Brochure - Posted 6/15/16