SF 894

as introduced - 88th Legislature (2013 - 2014) Posted on 03/21/2014 02:11pm

A bill for an act
relating to health; making changes to resident reimbursement classifications;
amending Minnesota Statutes 2012, section 144.0724.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA:

Section 1.

Minnesota Statutes 2012, section 144.0724, is amended to read:

144.0724 RESIDENT REIMBURSEMENT CLASSIFICATION.

Subdivision 1.

Resident reimbursement new text begin case mix new text end classifications.

The
commissioner of health shall establish resident reimbursement classifications based
upon the assessments of residents of nursing homes and boarding care homes conducted
under this section and according to section 256B.438. deleted text begin The reimbursement classifications
established under this section shall be implemented after June 30, 2002, but no later
than January 1, 2003.
deleted text end

Subd. 2.

Definitions.

For purposes of this section, the following terms have the
meanings given.

(a) "Assessment reference date" new text begin or "ARD" new text end means the deleted text begin last day of the minimum data
set observation period. The date sets the designated endpoint of the common observation
period, and all minimum data set items refer back in time from that point. deleted text end new text begin specific end
point for look-back periods in the MDS assessment process. This look-back period is also
called the observation or assessment period.
new text end

(b) "Case mix index" means the weighting factors assigned to the deleted text begin RUG-III or
deleted text end RUG-IV classifications.

(c) "Index maximization" means classifying a resident who could be assigned to
more than one category, to the category with the highest case mix index.

(d) "Minimum data set" new text begin or "MDS" new text end means deleted text begin the assessment instrument deleted text end new text begin a core set
of screening, clinical assessment, and functional status elements, that include common
definitions and coding categories new text end specified by the Centers for Medicare and Medicaid
Services and designated by the Minnesota Department of Health.

(e) "Representative" means a person who is the resident's guardian or conservator,
the person authorized to pay the nursing home expenses of the resident, a representative
of the deleted text begin nursing home ombudsman's deleted text end Office new text begin of Ombudsman for Long-Term Care new text end whose
assistance has been requested, or any other individual designated by the resident.

(f) "Resource utilization groups" or "RUG" means the system for grouping a nursing
facility's residents according to their clinical and functional status identified in data
supplied by the facility's minimum data set.

(g) "Activities of daily living" means grooming, dressing, bathing, transferring,
mobility, positioning, eating, and toileting.

(h) "Nursing facility level of care determination" means the assessment process
that results in a determination of a resident's or prospective resident's need for nursing
facility level of care as established in subdivision 11 for purposes of medical assistance
payment of long-term care services for:

(1) nursing facility services under section 256B.434 or 256B.441;

(2) elderly waiver services under section 256B.0915;

(3) CADI and BI waiver services under section 256B.49; and

(4) state payment of alternative care services under section 256B.0913.

deleted text begin Subd. 3. deleted text end

deleted text begin Resident reimbursement classifications prior to January 1, 2012. deleted text end

deleted text begin (a)
Resident reimbursement classifications shall be based on the minimum data set, version
3.0 assessment instrument, or its successor version mandated by the Centers for Medicare
and Medicaid Services that nursing facilities are required to complete for all residents.
Prior to January 1, 2012, the commissioner of health shall establish resident classes
according to the 34 group, resource utilization groups, version III or RUG-III model.
Resident classes must be established based on the individual items on the minimum data
set and must be completed according to the facility manual for case mix classification
issued by the Minnesota Department of Health.
deleted text end

deleted text begin (b) Each resident must be classified based on the information from the minimum
data set according to general domains in clauses (1) to (7):
deleted text end

deleted text begin (1) extensive services where a resident requires intravenous feeding or medications,
suctioning, or tracheostomy care, or is on a ventilator or respirator;
deleted text end

deleted text begin (2) rehabilitation where a resident requires physical, occupational, or speech therapy;
deleted text end

deleted text begin (3) special care where a resident has cerebral palsy; quadriplegia; multiple sclerosis;
pressure ulcers; ulcers; fever with vomiting, weight loss, pneumonia, or dehydration;
surgical wounds with treatment; or tube feeding and aphasia; or is receiving radiation
therapy;
deleted text end

deleted text begin (4) clinically complex status where a resident has tube feeding, burns, coma,
septicemia, pneumonia, internal bleeding, chemotherapy, dialysis, oxygen, transfusions,
foot infections or lesions with treatment, hemiplegia/hemiparesis, physician visits or order
changes, or diabetes with injections and order changes;
deleted text end

deleted text begin (5) impaired cognition where a resident has poor cognitive performance;
deleted text end

deleted text begin (6) behavior problems where a resident exhibits wandering or socially inappropriate
or disruptive behavior, has hallucinations or delusions, is physically or verbally abusive
toward others, or resists care, unless the resident's other condition would place the resident
in other categories; and
deleted text end

deleted text begin (7) reduced physical functioning where a resident has no special clinical conditions.
deleted text end

deleted text begin (c) The commissioner of health shall establish resident classification according to a
34 group model based on the information on the minimum data set and within the general
domains listed in paragraph (b), clauses (1) to (7). Detailed descriptions of each resource
utilization group shall be defined in the facility manual for case mix classification issued
by the Minnesota Department of Health. The 34 groups are described as follows:
deleted text end

deleted text begin (1) SE3: requires four or five extensive services;
deleted text end

deleted text begin (2) SE2: requires two or three extensive services;
deleted text end

deleted text begin (3) SE1: requires one extensive service;
deleted text end

deleted text begin (4) RAD: requires rehabilitation services and is dependent in activity of daily living
(ADL) at a count of 17 or 18;
deleted text end

deleted text begin (5) RAC: requires rehabilitation services and ADL count is 14 to 16;
deleted text end

deleted text begin (6) RAB: requires rehabilitation services and ADL count is ten to 13;
deleted text end

deleted text begin (7) RAA: requires rehabilitation services and ADL count is four to nine;
deleted text end

deleted text begin (8) SSC: requires special care and ADL count is 17 or 18;
deleted text end

deleted text begin (9) SSB: requires special care and ADL count is 15 or 16;
deleted text end

deleted text begin (10) SSA: requires special care and ADL count is seven to 14;
deleted text end

deleted text begin (11) CC2: clinically complex with depression and ADL count is 17 or 18;
deleted text end

deleted text begin (12) CC1: clinically complex with no depression and ADL count is 17 or 18;
deleted text end

deleted text begin (13) CB2: clinically complex with depression and ADL count is 12 to 16;
deleted text end

deleted text begin (14) CB1: clinically complex with no depression and ADL count is 12 to 16;
deleted text end

deleted text begin (15) CA2: clinically complex with depression and ADL count is four to 11;
deleted text end

deleted text begin (16) CA1: clinically complex with no depression and ADL count is four to 11;
deleted text end

deleted text begin (17) IB2: impaired cognition with nursing rehabilitation and ADL count is six to ten;
deleted text end

deleted text begin (18) IB1: impaired cognition with no nursing rehabilitation and ADL count is six
to ten;
deleted text end

deleted text begin (19) IA2: impaired cognition with nursing rehabilitation and ADL count is four or
five;
deleted text end

deleted text begin (20) IA1: impaired cognition with no nursing rehabilitation and ADL count is four
or five;
deleted text end

deleted text begin (21) BB2: behavior problems with nursing rehabilitation and ADL count is six to ten;
deleted text end

deleted text begin (22) BB1: behavior problems with no nursing rehabilitation and ADL count is
six to ten;
deleted text end

deleted text begin (23) BA2: behavior problems with nursing rehabilitation and ADL count is four to
five;
deleted text end

deleted text begin (24) BA1: behavior problems with no nursing rehabilitation and ADL count is
four to five;
deleted text end

deleted text begin (25) PE2: reduced physical functioning with nursing rehabilitation and ADL count
is 16 to 18;
deleted text end

deleted text begin (26) PE1: reduced physical functioning with no nursing rehabilitation and ADL
count is 16 to 18;
deleted text end

deleted text begin (27) PD2: reduced physical functioning with nursing rehabilitation and ADL count
is 11 to 15;
deleted text end

deleted text begin (28) PD1: reduced physical functioning with no nursing rehabilitation and ADL
count is 11 to 15;
deleted text end

deleted text begin (29) PC2: reduced physical functioning with nursing rehabilitation and ADL count
is nine or ten;
deleted text end

deleted text begin (30) PC1: reduced physical functioning with no nursing rehabilitation and ADL
count is nine or ten;
deleted text end

deleted text begin (31) PB2: reduced physical functioning with nursing rehabilitation and ADL count
is six to eight;
deleted text end

deleted text begin (32) PB1: reduced physical functioning with no nursing rehabilitation and ADL
count is six to eight;
deleted text end

deleted text begin (33) PA2: reduced physical functioning with nursing rehabilitation and ADL count
is four or five; and
deleted text end

deleted text begin (34) PA1: reduced physical functioning with no nursing rehabilitation and ADL
count is four or five.
deleted text end

Subd. 3a.

Resident reimbursement classifications beginning January 1, 2012.

(a) Beginning January 1, 2012, resident reimbursement classifications shall be based
on the minimum data set, version 3.0 assessment instrument, or its successor version
mandated by the Centers for Medicare and Medicaid Services that nursing facilities are
required to complete for all residents. The commissioner of health shall establish resident
deleted text begin classes deleted text end new text begin classifications new text end according to the new text begin RUG-IV, new text end 48 group, resource utilization groups.
Resident deleted text begin classes deleted text end new text begin classification new text end must be established based on the individual items on the
minimum data set, which must be completed according to the Long Term Care Facility
Resident Assessment Instrument User's Manual Version 3.0 or its successor issued by the
Centers for Medicare and Medicaid Services.

(b) Each resident must be classified based on the information from the minimum data
set according to general deleted text begin domains deleted text end new text begin categories new text end as defined in the deleted text begin Facility Manual for deleted text end Case Mix
Classification new text begin Manual for Nursing Facilities new text end issued by the Minnesota Department of Health.

Subd. 4.

Resident assessment schedule.

(a) A facility must conduct and
electronically submit to the commissioner of health deleted text begin case mix deleted text end new text begin MDS new text end assessments that
conform with the assessment schedule defined by Code of Federal Regulations, title 42,
section 483.20, and published by the United States Department of Health and Human
Services, Centers for Medicare and Medicaid Services, in the Long Term Care Assessment
Instrument User's Manual, version 3.0, and subsequent updates when issued by the
Centers for Medicare and Medicaid Services. The commissioner of health may substitute
successor manuals or question and answer documents published by the United States
Department of Health and Human Services, Centers for Medicare and Medicaid Services,
to replace or supplement the current version of the manual or document.

(b) The assessments used to determine a case mix classification for reimbursement
include the following:

(1) a new admission assessment deleted text begin must be completed by day 14 following admission deleted text end ;

(2) an annual assessment which must have an assessment reference date (ARD)
new text begin within 92 days of the previous assessment and new text end within 366 days of the ARD of the deleted text begin last
deleted text end new text begin previous new text end comprehensive assessment;

(3) a significant change new text begin in status new text end assessment must be completed within 14 days of
the identification of a significant change; deleted text begin and
deleted text end

(4) all quarterly assessments must have an assessment reference date (ARD) within
92 days of the ARD of the previous assessment deleted text begin . deleted text end new text begin ;
new text end

new text begin (5) any significant correction to a prior comprehensive assessment, if the assessment
being corrected is the current one being used for RUG classification; and
new text end

new text begin (6) any significant correction to a prior quarterly assessment, if the assessment being
corrected is the current one being used for RUG classification.
new text end

(c) In addition to the assessments listed in paragraph (b), the assessments used to
determine nursing facility level of care include the following:

(1) preadmission screening completed under section 256B.0911, subdivision 4a,
by a county, tribe, or managed care organization under contract with the Department
of Human Services; and

(2) a face-to-face long-term care consultation assessment completed under section
256B.0911, subdivision 3a, 3b, or 4d, by a county, tribe, or managed care organization
under contract with the Department of Human Services.

Subd. 5.

Short stays.

(a) A facility must submit to the commissioner of health an
deleted text begin initial deleted text end admission assessment for all residents who stay in the facility deleted text begin less than deleted text end 14 days new text begin or
less new text end .

(b) Notwithstanding the admission assessment requirements of paragraph (a), a
facility may elect to accept a short stay rate with a case mix index of 1.0 for all facility
residents who stay deleted text begin less than deleted text end 14 days new text begin or less new text end in lieu of submitting an deleted text begin initial deleted text end new text begin admission
new text end assessment. Facilities shall make this election annually.

(c) Nursing facilities must elect one of the options described in paragraphs (a) and
(b) by reporting to the commissioner of health, as prescribed by the commissioner. The
election is effective on July 1 each year.

deleted text begin (d) For residents who are admitted or readmitted and leave the facility on a frequent
basis and for whom readmission is expected, the resident may be discharged on an
extended leave status. This status does not require reassessment each time the resident
returns to the facility unless a significant change in the resident's status has occurred since
the last assessment. The case mix classification for these residents is determined by the
facility election made in paragraphs (a) and (b).
deleted text end

Subd. 6.

Penalties for late or nonsubmission.

A facility that fails to complete
or submit an assessment new text begin according to subdivisions 4 and 5 new text end for a deleted text begin RUG-III or deleted text end RUG-IV
classification within seven days of the time requirements deleted text begin in subdivisions 4 and 5 deleted text end new text begin listed in
the Long-Term Care Facility Resident Assessment Instrument User's Manual new text end is subject to
a reduced rate for that resident. The reduced rate shall be the lowest rate for that facility.
The reduced rate is effective on the day of admission for new admission assessments new text begin , on
the ARD for significant change in status assessments, new text end or on the day that the assessment
was due for all other assessments and continues in effect until the first day of the month
following the date of submission new text begin and acceptance new text end of the resident's assessment.

Subd. 7.

Notice of resident reimbursement classification.

(a) The commissioner
of health shall provide to a nursing facility a notice for each resident of the reimbursement
classification established under subdivision 1. The notice must inform the resident of the
classification that was assigned, the opportunity to review the documentation supporting
the classification, the opportunity to obtain clarification from the commissioner, and the
opportunity to request a reconsideration of the classification new text begin and the address and telephone
number of the Office of Ombudsman for Long-Term Care new text end . The commissioner must
transmit the notice of resident classification by electronic means to the nursing facility.
A nursing facility is responsible for the distribution of the notice to each resident, to the
person responsible for the payment of the resident's nursing home expenses, or to another
person designated by the resident. This notice must be distributed within three working
days after the facility's receipt of the electronic file of notice of case mix classifications
from the commissioner of health.

(b) If a facility submits a deleted text begin correction deleted text end new text begin modification new text end to the most recent assessment
used to establish a case mix classification conducted under subdivision 3 that results in a
change in case mix classification, the facility shall give written notice to the resident or the
resident's representative about the item that was deleted text begin corrected deleted text end new text begin modified new text end and the reason for the
deleted text begin correction deleted text end new text begin modification new text end . The notice of deleted text begin corrected deleted text end new text begin modified new text end assessment may be provided
at the same time that the resident or resident's representative is provided the resident's
deleted text begin corrected deleted text end new text begin modified new text end notice of classification.

Subd. 8.

Request for reconsideration of resident classifications.

(a) The resident,
or resident's representative, or the nursing facility or boarding care home may request that
the commissioner of health reconsider the assigned reimbursement classification. The
request for reconsideration must be submitted in writing to the commissioner within
30 days of the day the resident or the resident's representative receives the resident
classification notice. The request for reconsideration must include the name of the
resident, the name and address of the facility in which the resident resides, the reasons for
the reconsideration, deleted text begin the requested classification changes, deleted text end and documentation supporting
the deleted text begin requested classification deleted text end new text begin request new text end . deleted text begin The documentation accompanying the reconsideration
request is limited to documentation which establishes that the needs of the resident at the
time of the assessment justify a classification which is different than the classification
established by the commissioner of health. deleted text end new text begin The documentation accompanying the
reconsideration request is limited to a copy of the MDS that determined the classification
and other documents that would support or change the MDS findings.
new text end

(b) Upon request, the nursing facility must give the resident or the resident's
representative a copy of the assessment form and the other documentation that was given
to the commissioner of health to support the assessment findings. The nursing facility
shall also provide access to and a copy of other information from the resident's record that
has been requested by or on behalf of the resident to support a resident's reconsideration
request. A copy of any requested material must be provided within three working days of
receipt of a written request for the information. new text begin Notwithstanding any law to the contrary,
the facility may not charge a fee for providing copies of the requested documentation.
new text end If a facility fails to provide the material within this time, it is subject to the issuance
of a correction order and penalty assessment under sections 144.653 and 144A.10.
Notwithstanding those sections, any correction order issued under this subdivision must
require that the nursing facility immediately comply with the request for information and
that as of the date of the issuance of the correction order, the facility shall forfeit to the
state a $100 fine for the first day of noncompliance, and an increase in the $100 fine by
$50 increments for each day the noncompliance continues.

(c) In addition to the information required under paragraphs (a) and (b), a
reconsideration request from a nursing facility must contain the following information: (i)
the date the reimbursement classification notices were received by the facility; (ii) the date
the classification notices were distributed to the resident or the resident's representative;
and (iii) a copy of a notice sent to the resident or to the resident's representative. This
notice must inform the resident or the resident's representative that a reconsideration
of the resident's classification is being requested, the reason for the request, that the
resident's rate will change if the request is approved by the commissioner, the extent of the
change, that copies of the facility's request and supporting documentation are available
for review, and that the resident also has the right to request a reconsideration. If the
facility fails to provide the required information new text begin listed in item (iii) new text end with the reconsideration
request, new text begin the commissioner may request that the facility provide the information within 14
calendar days. new text end The new text begin reconsideration new text end request must be denied new text begin if the information is then not
provided new text end , and the facility may not make further reconsideration requests on that specific
reimbursement classification.

(d) Reconsideration by the commissioner must be made by individuals not involved
in reviewing the assessment, audit, or reconsideration that established the disputed
classification. The reconsideration must be based upon the deleted text begin initial deleted text end assessment new text begin that
determined the classification new text end and upon the information provided to the commissioner
under paragraphs (a) and (b). If necessary for evaluating the reconsideration request, the
commissioner may conduct on-site reviews. Within 15 working days of receiving the
request for reconsideration, the commissioner shall affirm or modify the original resident
classification. The original classification must be modified if the commissioner determines
that the assessment resulting in the classification did not accurately reflect deleted text begin the needs or
assessment deleted text end characteristics of the resident at the time of the assessment. The resident and
the nursing facility or boarding care home shall be notified within five working days after
the decision is made. A decision by the commissioner under this subdivision is the final
administrative decision of the agency for the party requesting reconsideration.

(e) The resident classification established by the commissioner shall be the
classification that applies to the resident while the request for reconsideration is pending.
If a request for reconsideration applies to an assessment used to determine nursing facility
level of care under subdivision 4, paragraph (c), the resident shall continue to be eligible
for nursing facility level of care while the request for reconsideration is pending.

(f) The commissioner may request additional documentation regarding a
reconsideration necessary to make an accurate reconsideration determination.

Subd. 9.

Audit authority.

(a) The commissioner shall audit the accuracy of resident
assessments performed under section 256B.438 through new text begin any of the following: new text end desk audits deleted text begin , deleted text end new text begin ;
new text end on-site review of residents and their records deleted text begin , deleted text end new text begin ; new text end and interviews with staff deleted text begin and deleted text end new text begin , residents, or
residents' new text end families. The commissioner shall reclassify a resident if the commissioner
determines that the resident was incorrectly classified.

(b) The commissioner is authorized to conduct on-site audits on an unannounced
basis.

(c) A facility must grant the commissioner access to examine the medical records
relating to the resident assessments selected for audit under this subdivision. The
commissioner may also observe and speak to facility staff and residents.

(d) The commissioner shall consider documentation under the time frames for
coding items on the minimum data set as set out in the new text begin Long-Term Care Facility new text end Resident
Assessment Instrument new text begin User's new text end Manual published by the Centers for Medicare and
Medicaid Services.

(e) The commissioner shall develop an audit selection procedure that includes the
following factors:

deleted text begin (1) The commissioner may target facilities that demonstrate an atypical pattern
of scoring minimum data set items, nonsubmission of assessments, late submission of
assessments, or a previous history of audit changes of greater than 35 percent. The
commissioner shall select at least 20 percent, with a minimum of ten assessments, of the
most current assessments submitted to the state for audit. Audits of assessments selected
in the targeted facilities must focus on the factors leading to the audit. If the number of
targeted assessments selected does not meet the threshold of 20 percent of the facility
residents, then a stratified sample of the remainder of assessments shall be drawn to meet
the quota. If the total change exceeds 35 percent, the commissioner may conduct an
expanded audit up to 100 percent of the remaining current assessments.
deleted text end

deleted text begin (2) Facilities that are not a part of the targeted group shall be placed in a general pool
from which facilities will be selected on a random basis for audit. Every deleted text end new text begin (1) Each new text end facility
shall be audited annually. If a facility has two successive audits in which the percentage of
change is five percent or less and the facility has not been the subject of a deleted text begin targeted deleted text end new text begin special
new text end audit in the past 36 months, the facility may be audited biannually. A stratified sample of
15 percent, with a minimum of ten assessments, of the most current assessments shall be
selected for audit. If more than 20 percent of the deleted text begin RUG-III or deleted text end RUG-IV classifications deleted text begin after
the audit deleted text end are changed new text begin as a result of the audit new text end , the audit shall be expanded to a second 15
percent sample, with a minimum of ten assessments. If the total change between the first
and second samples deleted text begin exceed deleted text end new text begin is new text end 35 percent new text begin or greater new text end , the commissioner may expand the
audit to all of the remaining assessments.

deleted text begin (3) deleted text end new text begin (2) new text end If a facility qualifies for an expanded audit, the commissioner may audit the
facility again within six months. If a facility has two expanded audits within a 24-month
period, that facility will be audited at least every six months for the next 18 months.

deleted text begin (4) deleted text end new text begin (3) new text end The commissioner may conduct special audits if the commissioner determines
that circumstances exist that could alter or affect the validity of case mix classifications of
residents. These circumstances include, but are not limited to, the following:

(i) frequent changes in the administration or management of the facility;

(ii) an unusually high percentage of residents in a specific case mix classification;

(iii) a high frequency in the number of reconsideration requests received from
a facility;

(iv) frequent adjustments of case mix classifications as the result of reconsiderations
or audits;

(v) a criminal indictment alleging provider fraud; deleted text begin or
deleted text end

(vi) other similar factors that relate to a facility's ability to conduct accurate
assessments deleted text begin . deleted text end new text begin ;
new text end

new text begin (vii) an atypical pattern of scoring minimum data set items;
new text end

new text begin (viii) nonsubmission of assessments;
new text end

new text begin (ix) late submission of assessments; or
new text end

new text begin (x) a previous history of audit changes of 35 percent or greater.
new text end

(f) Within 15 working days of completing the audit process, the commissioner shall
make available electronically the results of the audit to the facility. If the results of the
audit reflect a change in the resident's case mix classification, a case mix classification
notice will be made available electronically to the facility, using the procedure in
subdivision 7, paragraph (a). The notice must contain the resident's classification and a
statement informing the resident, the resident's authorized representative, and the facility
of their right to review the commissioner's documents supporting the classification and to
request a reconsideration of the classification. This notice must also include the address
and telephone number of the deleted text begin area nursing home ombudsman deleted text end new text begin Office of Ombudsman for
Long-Term Care new text end .

Subd. 10.

Transition.

After implementation of this section, reconsiderations
requested for classifications made under section 144.0722, subdivision 1, shall be
determined under section 144.0722, subdivision 3.

Subd. 11.

Nursing facility level of care.

(a) For purposes of medical assistance
payment of long-term care services, a recipient must be determined, using assessments
defined in subdivision 4, to meet one of the following nursing facility level of care criteria:

(1) the person requires formal clinical monitoring at least once per day;

(2) the person needs the assistance of another person or constant supervision to begin
and complete at least four of the following activities of living: bathing, bed mobility,
dressing, eating, grooming, toileting, transferring, and walking;

(3) the person needs the assistance of another person or constant supervision to begin
and complete toileting, transferring, or positioning and the assistance cannot be scheduled;

(4) the person has significant difficulty with memory, using information, daily
decision making, or behavioral needs that require intervention;

(5) the person has had a qualifying nursing facility stay of at least 90 days;

(6) the person meets the nursing facility level of care criteria determined 90 days
after admission or on the first quarterly assessment after admission, whichever is later; or

(7) the person is determined to be at risk for nursing facility admission or
readmission through a face-to-face long-term care consultation assessment as specified
in section 256B.0911, subdivision 3a, 3b, or 4d, by a county, tribe, or managed care
organization under contract with the Department of Human Services. The person is
considered at risk under this clause if the person currently lives alone or will live alone
upon discharge and also meets one of the following criteria:

(i) the person has experienced a fall resulting in a fracture;

(ii) the person has been determined to be at risk of maltreatment or neglect,
including self-neglect; or

(iii) the person has a sensory impairment that substantially impacts functional ability
and maintenance of a community residence.

(b) The assessment used to establish medical assistance payment for nursing facility
services must be the most recent assessment performed under subdivision 4, paragraph
(b), that occurred no more than 90 calendar days before the effective date of medical
assistance eligibility for payment of long-term care services. In no case shall medical
assistance payment for long-term care services occur prior to the date of the determination
of nursing facility level of care.

(c) The assessment used to establish medical assistance payment for long-term care
services provided under sections 256B.0915 and 256B.49 and alternative care payment
for services provided under section 256B.0913 must be the most recent face-to-face
assessment performed under section 256B.0911, subdivision 3a, 3b, or 4d, that occurred
no more than 60 calendar days before the effective date of medical assistance eligibility
for payment of long-term care services.

Subd. 12.

Appeal of nursing facility level of care determination.

A resident or
prospective resident whose level of care determination results in a denial of long-term care
services can appeal the determination as outlined in section 256B.0911, subdivision 3a,
paragraph (h), clause (7).