I. A person is medicaid eligible for nursing facility services or Medicaid home and community-based care waiver services if the person is:
(a) Clinically eligible for nursing facility care because the person requires 24-hour care for one or more of the following purposes:
(1) Medical monitoring and nursing care when the skills of a licensed medical professional are needed to provide safe and effective services;
(2) Restorative nursing or rehabilitative care with patient-specific goals;
(3) Medication administration by oral, topical, intravenous, intramuscular, or subcutaneous injection, or intravenous feeding for treatment of recent or unstable conditions requiring medical or nursing intervention; or
(4) Assistance with 2 or more activities of daily living involving eating, toileting, transferring, bathing, dressing, and continence; and
(b) Financially eligible as either:
(1) Categorically needy, as calculated pursuant to rules adopted by the department under RSA 541-A; or
(2) Medically needy, as calculated pursuant to rules adopted by the department under RSA 541-A.
II. Skilled professional medical personnel employed by or designated to act on behalf of the department shall determine clinical eligibility in accordance with the criteria in subparagraph I(a). The clinical eligibility determination shall be based upon an assessment tool, approved by the department, performed by skilled professional medical personnel employed by the department, or by an individual with equivalent training designated by the department. The department shall train all persons performing the assessment to use the assessment tool. For the purposes of this section, "skilled professional medical personnel" shall have the same meaning as in 42 C.F.R. section 432.50(d)(1)(ii).
II-a. Subject to written approval by the Center for Medicare and Medicaid Services, financial eligibility rules in paragraph II shall include eligibility if the person’s countable income is at or below the nursing facility special income standard, as defined in 42 C.F.R. 435.236, for the Medicaid program or the person incurs allowable medical expenses each month, including the anticipated cost of waiver services, which when deducted from the individual’s income would reduce the individual’s income to an amount that is no higher than the nursing facility special income standard. The department shall submit a request for such approval within 30 days of the effective date of this paragraph.
III. [Repealed.]
IV. If the skilled professional medical personnel employed by or designated to act on behalf of the department are unable to determine that an applicant is eligible following the clinical assessment tool pursuant to paragraph II, the skilled professional medical personnel shall obtain and give substantial weight to clinical information provided by the applicant’s physician or nurse practitioner, including, but not limited to diagnosis, prognosis, and plan of care recommendations, and consider information from other licensed practitioners, including occupational or physical therapists, if available. All clinical information obtained shall also be used in the preparation of the initial support plan.
Source. 1998, 388:1. 2003, 223:10, eff. July 1, 2003. 2005, 175:2, eff. Jan. 1, 2006; 175:21, eff. Aug. 29, 2005. 2007, 330:6, 7, eff. Jan. 1, 2008; 330:11, eff. June 30, 2007. 2008, 168:1, eff. June 6, 2008. 2010, Sp. Sess., 1:86, eff. June 10, 2010. 2011, 224:30, eff. July 1, 2011. 2014, 33:1, eff. May 27, 2014. 2015, 145:1-3, eff. Aug. 11, 2015.