The State of Maryland offers nursing facility services to Medicaid participants who meet certain financial and medical requirements. The State of Maryland serves over 20,000 participants each year in nursing facilities.
Frequently Asked Questions
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). This can be done by mail or in person at your local Department of Social Services. Be sure to bring with you documentation of your income and resources, including unpaid bills or receipts for medical services (if you apply in person), or (if you apply by mail) be prepared to send copies of them when the eligibility worker begins to process the application and requests additional information.
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 intellectual disabilities (or related conditions) and/or serious mental illness receive services in the least restrictive appropriate setting. PASRR is also designed to make sure individuals who need nursing facility services are provided the services that will meet their unique needs.
Under PASRR, nursing facilities may not admit or retain an individual who has a serious mental illness, intellectual disability, or a related condition unless the Developmental Disabilities Administration (DDA) or the Behavioral Health Administration (BHA) 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 the method by which an individual’s nursing facility stay will be paid.
During the admission process, the discharging hospital or admitting nursing facility screens potential new admissions using the Level I Screening Form. If the individual is suspected of having a serious mental illness, intellectual disability or a related condition (also known as a “positive screen”), the hospital or nursing facility contacts the local health department (LHD) in that jurisdiction* to evaluate the individual. The LHD evaluates the individual’s medical, social and functional status. Once the evaluation is complete, the LHD sends its findings to the DDA or the BHA, which determines whether nursing facility admission is appropriate and what, if any, specialized services the individual requires.
Once admitted, if the individual’s condition changes, the nursing facility contacts the LHD for a new evaluation and determination regarding continued stay in the nursing facility and/or the provision of specialized services.
*In some jurisdictions, the unit conducting the Level II Evaluation is known as Adult Evaluation and Review Services (AERS).
Residents, families, nursing facilities, and others can get more information on PASRR here.
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 file 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. Please visit the Department's Home and Community Based Programs site for more information or see the following flyer entitled Get Long Term Services and Supports in the Community!
For additional information, contact a nursing facility staff specialist at 410-767-1736.
