Nursing facility ineligible reassessment and certification forms (MA570)

Community HealthChoices patients are required to renew their Community HealthChoices Medicaid eligibility for home- and community-based services in order to continue receiving services and supports in their home rather than needing to receive assistance in an institutional setting such as a nursing facility, ICF/ORC, or other institutional setting. The Pennsylvania Physician Certification Form, also called the MA570, is a required part of the eligibility determination for Community HealthChoices programs.

You may be receiving outreach calls or correspondence from service coordinators, physician account executives, or clinical improvement specialists reminding you that completion of these forms is necessary to prevent delays with your patient’s application. The renewal application requires that the MA570 form be completed in its entirety and signed by an MD or DO. On the form, please remember to indicate your patient’s level of care using the definitions provided on the MA570 form itself. For patients meeting ICF/ORC, page 2 of this form must also be completed. Below is a summary of each available level of care option. It is important to remember that you are only recommending the appropriate level of care for your patient, not determining which setting is most appropriate for them to receive their services.

Nursing Facility Clinically Eligible (NFCE) – The individual has an illness, injury, disability, or medical condition diagnosed by a physician; and as a result of that diagnosed illness, injury, disability, or medical condition, the individual requires care and services above the level of room and board. A physician certifies that the individual is NFCE; and the care and services are either a) skilled nursing or rehabilitation services as specified by the Medicare Program in 42 CFR §§ 409.31(a), 409.31(b)(1) and (3), and 409.32 through 409.35; or b) health-related care and services that may not be as inherently complex as skilled nursing or rehabilitation services, but which are needed and provided on a regular basis in the context of a planned program of health care and management and were previously available only through institutional facilities.

Nursing Facility Ineligible (NFI) – Individuals who do not meet the definition of Nursing Facility Clinically Eligible are considered NFI.

Intermediate Care Facility for Persons with Other Related Conditions (ICF/ORC) – The individual has a diagnosis of Other Related Condition (ORC), a severe, chronic disability (other than a mental illness or an intellectual disability)that manifested before age 22, is likely to continue indefinitely, results in an impairment of either general intellectual functioning or adaptive behavior, and results in substantial functional limitations in at least three of these areas: self-care, understanding and use of language, learning, mobility, self-direction, and capacity of independent living, and requires active treatment—a continuous program that aggressively and consistently gives specialized and generic training, treatment, health services and related services; that focuses on the client acquiring behaviors necessary to function with as much self-determination and independence as possible; and that aims to prevent or slow regression or loss of current optimal functional status.

To prevent delays with your patient’s application, please complete, sign, and return the form to chcscentral@upmc.edu from a secure email or by fax to 1-844-890-7458 as soon as possible, but within 14 days of receipt to avoid any disruption in services or Medicaid eligibility.