ODP Announcement 19-017 provides guidance for assisting individuals with transitioning from nursing facilities into waiver services. When an individual is in reserved waiver capacity status, due to requiring hospital and/or nursing home care beyond 30 days, or has been identified as eligible to receive services offered in an ODP waiver upon discharge from the nursing facility, the AE, county MH/ID program, SC, or TSM provider will need to assist the individual in transitioning from the nursing facility. As part of the transition process, a PA 1768 form needs to be completed.
It is important that the PA 1768 form is completed and submitted to the County Assistance Office (CAO) prior to the individual’s discharge, so that there is no interruption in service. The submission of the PA 1768 form in advance of the anticipated discharge date allows the CAO to enter a waiver code in the individual’s record.
The nursing facility will coordinate with the individual and family, the AE, county MH/ID program, SC, or TSM provider as appropriate, to determine an anticipated date of discharge from the nursing facility. The individual must begin to receive waiver services on the day he or she is discharged from the nursing facility.
The AE, county MH/ID program, SC, or TSM provider is responsible to complete the PA 1768 form. The completed PA 1768 form will be sent to the CAO at least two weeks prior to the anticipated date of discharge. For more information about completing the PA 1768, please refer to ODP bulletin 00-18-02, Home and Community-Based Services (HCBS) Eligibility/Ineligibility/Change Form (PA 1768) and Instructions.
The nursing facility is responsible to complete and submit the Long Term Care Admission Discharge Transmittal form (MA 103) to the CAO when the individual is discharged from the nursing facility. During the transition process, if the AE, county MH/ID program, SC, or TSM provider becomes aware that the nursing facility did not complete and submit the MA 103 to the CAO, a request should be made to the nursing facility to complete and submit this form. Enrollment into a waiver cannot be completed until the CAO receives the MA 103. Depending on the individual’s circumstances, the actual discharge date may be sooner or later than the originally anticipated discharge date, or the individual may not be discharged at all.
Please direct questions regarding this Announcement to the appropriate ODP Regional Office.