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YOUR
RIGHTS IF YOU RECEIVE A NOTICE THAT YOU ARE NOT ELIGIBLE
FOR
MEDICAID-FUNDED LONG TERM CARE SERVICES.
As
of November 1, 2004, Michigan began using a new electronic web-based
screening tool to decide whether people who are financially eligible for
Medicaid are also medically in need of nursing home care or similar care in
their own homes.
All
Medicaid-eligible individuals seeking admission to a nursing facility,
the MI Choice program, or the PACE program or seeking re-certification of
Medicaid must now be screened in seven areas:
Activities of Daily Living
Cognitive Performance
Physician
Involvement
Treatments and Conditions
Skilled
Rehabilitation Therapies
Behavior
Service
Dependency
Medicaid-eligible
individuals who must be
screened include:
those already residing in a facility who have just qualified for Medicaid
those already qualified for Medicaid who have completed or declined
Medicare-funded rehabilitation and who are returning to a Medicaid bed.
non-emergency transfers from another
nursing facility where they had been
receiving Medicaid coverage
current Medicaid-eligible residents who were admitted prior to November
1, 2004, and who will be screened at the time of their 12-month re-certification of Medicaid nursing home eligibility
Medicaid-eligible
persons who are determined not to need nursing facility level of care in ANY
of the seven screening areas will receive one of two types of Adverse Action
Notice. These written notices will come from the Nursing
Facility, MI Choice Provider or PACE provider.
You
may then request any or all, together or separately, of the following:
Exception
Process:
To obtain an Immediate
Review, you must contact the Michigan Peer Review Organization (MPRO) at
1-800-727-7223 before 12:00 PM (noon) on the date following your receipt of the Adequate
Action Notice.
MPRO
will review your medical records and other information about whether your needs
could be met outside a nursing facility or the MI Choice program. MPRO may
decide to issue an EXCEPTION allowing you to be admitted to the nursing
facility or MI Choice. If MPRO
agrees that you are not eligible for nursing facility level of care, you
still have the right to request a Medicaid Fair Hearing.
A
Second Screening:
If you feel that the first
screening was not accurate because it contained incorrect or incomplete
information about your needs, you may request that the screening be redone.
The second screening must be dated with the date on which it is given. It
is not necessary to wait any specific time period before requesting a second
screening. It may be requested the
same day as the first screening.
If
you qualify under the second screening, the Michigan Department of Community
Health may conduct a review of your medical records to insure that the second
screening was accurate.
Medicaid
Fair Hearing:
To request a Medicaid Fair Hearing, you must complete a "Request for an
Administrative Hearing" (DCH-0092) form and mail it to:
Administrative
Tribunal
Michigan
Department of Community Health
P.O.
Box 30195
Lansing,
Michigan 48909-7695
The
Medicaid Fair Hearing Request MUST be received within 90 calendar
days of the date of the Adequate Action Notice or Advance Action
Notice, in writing, and signed by you or a person authorized
to sign it for you.
If
you have been allowed to stay in the nursing facility or MI Choice and do not
receive an exception or win your hearing, the Michigan Department of Community
Health will recover any Medicaid payments made to the facility and the facility
may seek to recover repayment from you in turn.
For assistance call:
1-866-485-9393
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