Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 43 - NURSING FACILITY LEVEL OF CARE DETERMINATION FOR CHILDREN › Section 471-43-003 - LEVEL OF CARE

Current through June 17, 2024
003.01
NURSING FACILITY LEVEL OF CARE (NF LOO CRITERIA.
The
  client or his or her authorized representative must provide information needed
  to determine nursing facility level of care (NF LOC). In order to make a
  determination, the client or representative must be assessed on the basis of
  activities of daily living (ADLs), risk factors, medical conditions and
  interventions, and cognitive function, to be determined via in-person
  discussion and observation of the client; reports from caregivers, family, and
  providers; and current medical records.
003.01(A)
LEVEL OF CARE (LOO
  DETERMINATION FOR CHILDREN AGE 17 OR YOUNGER.
To meet nursing
  facility level of care (NF LOC) eligibility, a child must have assessed
  limitations in the child level of care (LOC) categories as follows:
(1) Children age 0-47 Months: To be eligible,
  the child must have needs related to a minimum of one defined medical condition
  or treatment as listed in this chapter: and
(2) Children age 48 months through 17 years:
  Nursing facility level of care (NFLOC) eligibility can be met in one of three
  ways:
(a) least one medical condition or
  treatment need:
(b) Limitations in
  at least six activities of daily living (ADD: or
(c) Limitations in at least four activities
  of daily living (ADD and the presence of at least two other considerations.
003.01(A)(i)
AGE.
For purposes of this section, the age of the
  child is his or her age on the last day of the month in which the level of care
  (LOC) determination is made.
003.01(A)(ii)
LEVEL OF CARE (LOC)
  CRITERIA.
The client or his or her authorized representative must
  provide the nursing facility level of care (NF LOC) information for use in the
  level of care determination which is obtained through in-person discussion,
  standardized assessment, and observation of the child: reports from parents or
  legal representative or informal caregivers; documentation from the child's
  individualized family service plan (IFSP) or individual education plan (IEP);
  and current medical records. Children with disabilities meet nursing facility
  level of care (NF LOC) eligibility based on the assessment categories of
  medical conditions and treatments, activities of daily living (ADD, and other
  considerations.
003.01(A)(ii)(1)
DETERMINATION OF MEDICAL CONDITIONS AND MEDICAL
  TREATMENTS.
To gualify with a limitation in this category, a child
  must have a defined, documented medical condition or receipt of treatment,
  which satisfies the reguirements of this chapter.
003.01(A)(ii)(1)(a)
DEFINED
  MEDICAL TREATMENT AND MEDICAL CONDITIONS.
The following medical
  conditions and treatments are considered in determining nursing facility level
  of care (NF LOC) eligibility:
(i) Defined
  medical treatments:
(1)
  Chemotherapy;
(2)
  Hemodialysis;
(3) Peritoneal
  dialysis;
(4) IV
  medication;
(5) Routine oxygen
  therapy;
(6) Radiation;
(7) Nasopharyngeal suctioning;
(8) Tracheotomy care;
(9) Transfusion;
(10) Ventilator or respirator;
(11) Wound care;
(12) Urinary catheter care;
(13) Continuous positive airway pressure
  (CPAP) or bi-level positive airway pressure (BiPAP);
(14) Percussion vest;
(15) Urinary collection device;
(a) Condom catheter;
(b) Indwelling catheter; or
(c) Cystostomy, nephrostomy,
  ureterostomy;
(16)
  Inadequate pain control;
(17) Mode
  of nutritional intake;
(a) Combined oral and
  parenteral or tube feeding;
(b)
  Nasogastric tube feeding;
(c)
  Abdominal feeding tube;
(d)
  Parenteral feeding; or
(18) Other treatment(s) that may reguire
  management through a nursing facility or hospitalization, evaluated through
  clinical review by the Department;
(ii) Defined medical conditions:
(1) Epilepsy;
(2) Conditions or diseases which make
  cognitive, activity of daily living, mood, or behavior patterns unstable
  including fluctuating, precarious, or deteriorating;
(3) End-stage disease, six or fewer months to
  live;
(4) Severe pressure
  ulcer;
(5) Deep craters in the
  skin;
(6) Breaks in skin exposing
  muscle or bone;
(7) Spinal cord
  dysfunction;
(8) Comatose or
  persistent vegetative state;
(9)
  Cerebral palsy;
(10) Macro or
  microcephaly;
(11) Muscular
  dystrophies;
(12) Seizure
  disorder;
(13) Traumatic brain
  injury;
(14) Congenital heart
  disorder;
(15) Cystic
  fibrosis;
(16) Cancer;
(17) Explicit terminal prognosis;
(18) Failure to thrive;
(19) Renal failure; or
(20) fluctuating, inconsistent medical
  condition that has reguired the child to receive hospitalization related to a
  single medical condition:
(a) One or more
  times in the past 90 days; or
(b)
  For at least 30 days, if the child is less than 12 months old; or
(iii) A condition which
  a licensed medical provider has documented as terminal or a persistent
  condition in which the absence of active treatment would result in
  hospitalization.
003.01(A)(ii)(1)(b)
ADDITIONAL
  CRITERIA FOR MEDICAL CONDITIONS AND TREATMENTS.
In addition to
  having a medical condition or treatment identified above, the present medical
  condition or treatment must:
(1) Impact the
  child's functioning or independence on a daily basis; and
(2) Require physical assistance of another
  person:
(a) To prevent a decline in health
  status: or
(b) When the child is
  physically or cognitively unable to self-perform the medically necessary
  treatments.
003.01(A)(ii)(1)(b)(i)
48 MONTHS
  THROUGH 17 YEARS.
For children ages 48 months through 17 years,
  documentation of the daily effect of a defined medical condition or treatment
  on the child's functioning or independence is reguired.