How is medical necessity determined for Medicaid nursing home care?

The state Medicaid claims administrator, Texas Medicaid & Health Partnership (“TMHP”), is responsible for making medical necessity determinations for nursing home Medicaid. TMHP makes its determination by evaluating the person’s medical and nursing needs based on the minimum data set (“MDS”) assessment prepared by a registered nurse. TMHP begins the medical necessity review process upon receiving an MDS assessment and the Long-Term Care Medicaid Information Section from a Medicaid contracted nursing facility.

In order for “medical necessity” to exist, TMHP must determine that the person meets the conditions set forth below:

1. The individual must demonstrate a medical condition that:

(A) is of sufficient seriousness that the individual’s needs exceed the routine care which may be given by an untrained person; and

(B) requires licensed nurses’ supervision, assessment, planning, and intervention that are available only in an institution.

2. The individual must require medical or nursing services that:

(A) are ordered by a physician;

(B) are dependent upon the individual’s documented medical conditions;

(D) are provided either directly by or under the supervision of a licensed nurse in an
institutional setting; and

(E) are required on a regular basis.

If an MDS assessment does not contain sufficient information for TMHP to make a medical necessity determination, the MDS assessment is placed on hold and the nursing facility is notified it has 21 days to provide sufficient information on the MDS assessment or medical necessity will be denied.

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