There are 240 nursing homes enrolled in the Maryland Medicaid Nursing
Home Program, resulting in approximately 30,000 nursing home beds
available to the program.
To apply for the program contact
the local Department of Social Services.
Qualified applicants must meet both the Medicaid Program’s financial and
medical requirements. The local Department of Social Services
determines financial eligibility. The Medicaid Program’s utilization
control agent determines medical eligibility, with input from the
applicant’s physician.
The
Maryland Medicaid nursing home rate setting system was established in
1983. The formula used to reimburse nursing homes is complex, and is
based in part upon a patient’s need for care, including the following
five activities of daily living: bathing, dressing, eating, mobility and
continence; and behavioral management. For more information regarding
the Nursing Home Program, call 410-767-1444.
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Frequently Asked Questions --FAQs |
I need to place a loved one in a nursing facility under Medical
Assistance. What do I need to do?
What does “medically eligible” mean? What are the medical
eligibility criteria for Medicaid nursing facility benefits?
What is PASRR?
How much does Medical Assistance pay nursing facilities?
How can I lodge a complaint about the care my loved one is receiving in
a nursing facility?
My loved one needs more care than I can give, but I do not want to admit
him/her to a nursing facility. Can we have help taking care of him/her
at home?
Suggested Links to other resources:
I need to place a loved one in a nursing facility under Medical
Assistance. What do I need to do?
First, apply for Medical Assistance through the local Department of
Social Services in the county where the applicant resides (if the
applicant is already in a nursing facility, the county in which the
facility is located). Generally, the applicant (or authorized
representative) must apply in person.
The applicant must be certified as medically eligible for
nursing facility services. If the applicant is already in a nursing
facility converting to Medical Assistance or in a hospital prior to
being admitted to a facility, the facility or hospital will apply for
medical eligibility. If the applicant is in another setting, the
applicant or representative must have the applicant’s physician
complete the Medical Eligibility Review Form, DHMH 3871 and
mail it to Delmarva Foundation for consideration. The physician must
also complete the MR/MI Screen Form as required under PASRR
and contact the
Adult Evaluation and Review Services (AERS) unit if necessary.
What does “medically eligible” mean? What are the medical eligibility
criteria for Medicaid nursing facility benefits?
The Maryland Medical Assistance Program pays for nursing facility
services only when it is “medically necessary,” that is, when a
person’s health condition is such that he requires care under the
full-time supervision of a licensed nurse. The need for intermittent,
part-time services (for example, home health nursing) does not qualify
one as medically eligible for nursing facility services, nor does the
need for unlicensed care (e.g., personal care) even if care is needed
full-time. If a person’s health condition is such that full-time care
under licensing nursing supervision is needed, that person is said to
be “medically eligible” for nursing facility services.
What is PASRR?
PASRR stands for Pre-Admission Screening and Resident Review.
Congress instituted PASRR in 1987 in an effort to ensure that
individuals with mental retardation (or related conditions) and mental
illness receive services in the least restrictive appropriate
setting. PASRR is also designed to make sure that these individuals
get the services they need to meet their unique needs.
Under PASRR, nursing facilities cannot admit or retain an individual
who has a serious mental illness, mental retardation, or a related
condition unless the Developmental Disabilities Administration (DDA)
or the Mental Hygiene Administration (MHA) has determined that a
nursing facility placement is appropriate for the individual. PASRR
applies to all new admissions to nursing facilities that participate
in the Medicaid Program, regardless of how the individual’s nursing
facility stay is being paid for.
During the admission process, the discharging hospital or admitting
nursing facility screens potential new admissions using the MR/MI
Screening Form. If the individual has a serious mental illness,
mental retardation or a related condition (also known as a “positive
screen”), the hospital or nursing facility will contact the Adult
Evaluation and Review Services (AERS) unit to evaluate the
individual. The AERS team consisting of a nursing and a social worker
will evaluate the individual’s medical and functional condition and
special needs. The team will send its findings to DDA or MHA, who
will determine whether nursing facility admission is appropriate and
what, if any, specialized services the individual requires.
Once admitted, if the resident’s condition changes, the nursing
facility will contact AERS for a new evaluation and determination
regarding continued stay in the nursing facility.
How much does Medical Assistance pay nursing facilities?
Maryland pays its nursing facilities under a “case-mix” system. This
means that, rather than paying all facilities one set rate, Medical
Assistance calculates separate sets of rates for each facility. These
rates depend on the individual facility’s operating costs; the amount
and type of care that each resident needs, and other factors.
How can I lodge a complaint about the care my loved one is receiving in
a nursing facility?
If you have reason to believe that an individual is not getting the
proper care, you may do one or more of the following:
-
Contact the long-term care
ombudsman in the Department of Aging office in the county in which the
facility is located. The ombudsman will investigate the complaint.
-
File a complaint with
the Office of Health Care Quality. This Office will investigate your
complaint. If your complaint is found to be valid, the Office may take
sanctions against the facility.
My loved one needs more care than I can give, but I do not want to admit
him/her to a nursing facility. Can we have help taking care of him/her
at home?
Maryland Medical Assistance pays for many long-term care services in the
community. These include:
Home and Community Based Services Waiver for Older Adults - Medical
Assistance pays for services in a licensed assisted living facility (not
including room and board), personal care, adaptive equipment,
home-delivered meals, and other services to qualified individuals age 50
and older who would otherwise be eligible for nursing facility
benefits. To learn more and to see if you qualify, contact the local
aging office in your county or call 1-800-AGE-DIAL.
Under the Living at
Home Program, Medical Assistance pays for attendant care and related
services to qualified individuals ages 18 - 59 who would otherwise be
eligible for nursing facility benefits. To learn more and to see if
you qualify, contact the Department of Health and Mental Hygiene Living
at Home Waiver Division at (410) 767-7479. For additional information
on this site, see Living at Home (
http://www.dhmh.state.md.us/mma/commchoic/index.html
) Waiver Program.
The
Program for All-Inclusive Care for the Elderly (PACE) - Medical
Assistance pays for day health care and other services through PACE,
a model of care in which all medical and nursing services (including
day health and home care) are provided by a single entity. The PACE
site in Maryland is Hopkins ElderPlus (HEP) located on the campus of
Johns Hopkins Bayview Medical Center. PACE is only available to people
who live in certain areas of Baltimore City. To learn more about this
program and to see if you qualify, contact Karen Armacost at (410)
550-7124.
Medical Day Care - Medical Assistance pays for medical day care services
for Medical Assistance recipients who qualify as medically eligible for
nursing facility services. See
Adult Day Care Services for more information on this program.
Personal Care - Medical Assistance pays for personal care for qualified
Medical Assistance recipients. To see if you qualify and to apply for
personal care services, please contact the health department in the
county in which you live. See
Personal Care Services for more information on this program.
Contact – nursing facility staff specialist at 410-767-1736 for more
information.
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