Form Dmas 95 – Fill Out and Use This PDF

Enter the Individual's Full Name, the Date of Birth as MM/DD/YYYY, the 9-digit Social Security Number and, if applicable, the 12-digit Medicaid Number.

Indicate whether the individual meets nursing facility level of care criteria. If yes is checked, complete the screening.

If no is checked, the individual does NOT meet nursing facility level of care criteria: do not complete the Level I screening and do not refer for a Level II evaluation. If NO, the individual should not be admitted to a NF nor be referred for a Level II Screening.

Can a safe and appropriate plan of care be developed to meet all services and supports including medical/nursing/custodial care needs? Yes or No. If the answer to #1 is Yes, the remainder of this form MUST BE COMPLETED.

For reference, level of care criteria can be found in the Medicaid Long-Term Services and Supports Manual Chapter IV found on the Virginia Medicaid portal.

Check yes (that the individual has a current diagnosis of serious MI) only if each item in 2- a, b and c is checked yes. Indicate the diagnosis if yes is checked. If any answer to a, b or c is no, then no is checked for the overall question and do not refer for Level II evaluation for mental illness.

Under a, check yes if the individual has a major mental disorder diagnosable under DSM (e.g., schizophrenia, mood, paranoid, panic, or other serious anxiety disorder; somatoform disorder; personality disorder; other psychotic disorder; or other mental disorder that may lead to a chronic disability).

Under b, check yes if the individual has a mental disorder that has resulted in functional limitations in major life activities within the past 3-6 months, particularly with regard to interpersonal functioning concentration, persistence, pace and adaptation to change.

Under c, check yes if the individual's treatment history indicates that he or she has experienced (1) psychiatric treatment more intense than outpatient care more than once in the past 2 years or (2) within the last 2 years, an episode of significant disruption to the normal living situation due to the mental disorder.

Check yes if the individual has a level of intellectual disability (mild, moderate, severe, or profound) described in the Classification in Mental Retardation: Chapter 3. American Association on Mental Deficiency (AAMD), 1983 that was manifested before age 18.

Check yes for answer for 4, only if each item in 4, a-d is checked yes. If any answer to a-d is no, then no is checked for the overall question and do not refer for Level II evaluation for related conditions.

Under a, check yes if the condition is attributable to any other condition, other than MI, found to be closely related to intellectual disability because this condition may result in impairment of general intellectual functioning or adaptive behavior similar to that of persons living with ID and requires treatment or services similar to those for persons living with ID.

Under b, check yes if the condition has manifested before age 22. Under c, check yes if the condition is likely to continue indefinitely.

Under d, check yes if the condition has resulted in substantial limitations in three (3) or more of the following areas of major life activity, self-care, understanding, use of language, learning, mobility, self-direction, and capacity for independent living.

Circle the applicable areas.

Either a or b must be checked.

Check this category if Question 2 is checked yes AND/OR either Question 3 or 4 is checked yes.

Refer for Level II evaluation. NF Placement = Level II refer to Ascend Maximus Management.

Check MI when # 2 is checked yes, ID or Related Condition when # 3 or # 4 is checked yes, and Dual diagnosis when MI and IDD or Related Condition categories are checked. If 5a is checked, the individual may NOT be authorized for Medicaid-funded NF LTSS until the Level II evaluation has been completed.

Indicate whether referral is for MI, ID or RC, the DATE LEVEL II REFERRAL MADE (the date the package is referred to the appropriate Level II evaluator), and where and to whom the package is sent.

No referral for Level II evaluation for active treatment needs: check this no referral needed category ONLY if there is documented evidence as follows.

Does not meet the applicable criteria for MI, ID or a related condition.

Has a primary diagnosis of dementia (including Alzheimer's disease), and if there is a diagnosis of ID this category does not apply; or has a primary diagnosis of dementia AND a secondary diagnosis of MI.

Has a severe physical illness (e.g. documented evidence of coma, functioning at brain-stem level, or other diagnoses) which results in a level of impairment so severe that the individual could not be expected to benefit from specialized services. If the answer determines that an illness not listed here is so severe that the individual could not be expected to benefit from specialized services, documentation describing the severe illness must be attached for review.

Is terminally ill (note: a physician must have documented that individual's life expectancy is six (6) months or less).

On the Signature & Title line, sign with the title, and fill in the Date.

The Staff assigned to conduct Level I Screening must complete the form prior to a Nursing Facility admission, for ALL individuals seeking one.