Last updated December 24, 2024
1. Look up the person in MMIS.
- Senior LinkAge Line will NOT conduct the PAS in the following situations OR make referrals for OBRA Level II screenings. This will be the responsibility of the receiving lead agency. Please note, more than one lead agency may receive a single referral. The Senior LinkAge Line will send notification to the nursing facility of the referral to the lead agency.
| The person is on: | Who receives the referral? | Purpose of Referral | Note examples |
| MSHO or MSC+ ONLY | Managed care plan only | MCO will conduct PAS | Client is open to MSHO, SLL forwarding for processing. |
| SNBC ONLY | Managed care plan | MCO will conduct PAS | Client is open to SNBC and under age 65. SLL forwarding PAS to _____ for processing and _____ county for the under 65 referral. |
| County of nursing facility location | Conduct 80th day assessment | Client is open to SNBC and under age 65. SLL forwarding PAS to _____ for processing and _____ county for the under 65 referral. | |
| MSHO or MSC+ with EW | Managed care plan only | MCO will forward to care coordinator and conduct waiver activities | Client is open to MSHO/MSC+ and EW, SLL forwarding for processing. **Tip: Check boxes on LA Referral form for both Managed Care and Waiver/AC/ECS |
| MSHO, MSC+ with DD waiver | Managed care plan AND County of financial responsibility | MCO will conduct PAS | Client is open to MSHO/MSC+ and DD waiver. SLL forwarding PAS to ____ for processing and ____ county for waiver activities. |
| Conduct waiver activities and OBRA Level II | Client is open to MSHO/MSC+ and DD waiver. SLL forwarding PAS to ____ for processing and ____ county for waiver activities. | ||
| MSHO, MSC+ with: CAC, CADI or BI | Managed care plan AND county of financial responsibility | Managed care plan needs to be made aware | Client is open to MSHO/MSC+ and CADI/CAC/BI. SLL forwarding PAS to _____ county for processing and _____ to be made aware. |
| Conduct appropriate waiver activities | Client is open to MSHO/MSC+ and CADI/CAC/BI. SLL forwarding PAS to _____ county for processing and _____ to be made aware. | ||
| SNBC with: CAC, CADI, BI | Managed care plan AND County of financial responsibility AND County of nursing facility location | Managed care plan needs to be made aware | Client is open to SNBC, CADI/CAC/BI, and under age 65. SLL forwarding PAS to ___ to make them aware, ____ county for processing, and ____ county for under age 65 referral. |
| Conduct appropriate waiver activities and relocation assistance | Client is open to SNBC, CADI/CAC/BI, and under age 65. SLL forwarding PAS to ___ to make them aware, ____ county for processing, and ____ county for under age 65 referral. | ||
| Conduct 80th day assessment | Client is open to SNBC, CADI/CAC/BI, and under age 65. SLL forwarding PAS to ___ to make them aware, ____ county for processing, and ____ county for under age 65 referral. | ||
| SNBC with DD waiver | Managed care plan AND County of financial responsibility AND County of nursing facility location | MCO will conduct PAS (the bulletin will be updated) | Client is open to SNBC, DD waiver, and is under age 65. SLL forwarding PAS to ___ for processing, ____ county for waiver activities, and ____ county for under 65 referral. |
| Conduct waiver activities and OBRA Level II | Client is open to SNBC, DD waiver, and is under age 65. SLL forwarding PAS to ___ for processing, ____ county for waiver activities, and ____ county for under 65 referral. | ||
| Conduct 80th day assessment | Client is open to SNBC, DD waiver, and is under age 65. SLL forwarding PAS to ___ for processing, ____ county for waiver activities, and ____ county for under 65 referral. | ||
| EW or AC | County of residence (COR on last screening in MMIS) | Conduct appropriate waiver activities | Client is open to EW/AC, SLL forwarding for processing. County of client’s current residence, as listed in last MMIS screening, is ________ County. |
| CAC, CADI or BI ONLY AND person is age 65 and older | County of financial responsibility | Conduct appropriate waiver activities | Client is open to CADI/CAC/BI, SLL forwarding for processing. |
| CAC, CADI, BI (no managed care) AND person is under age 65 | County of financial responsibility AND county of nursing facility location | Conduct appropriate waiver activities | Client is open to CADI/CAC/BI and is under age 65. SLL forwarding PAS to ___ county for waiver activities and ___ county for under age 65 referral. |
| Conduct 80th day assessment | Client is open to CADI/CAC/BI and is under age 65. SLL forwarding PAS to ___ county for waiver activities and ___ county for under age 65 referral. | ||
| Person is under age 21 ONLY (Or under 21 and on DD Waiver only) *If on programs, follow steps above | County of person location (At the time of PAS submission. This is usually the county of the hospital or clinic) | County will conduct face-to-face assessment | Client under age 21, SLL forwarding for processing. |
- Senior LinkAge Line will complete a PAS for all other individuals. However, referrals to a lead agency may be necessary after the PAS is conducted. The following provides guidance on referrals AFTER the PAS is conducted by the Senior LinkAge Line.
- Even if a referral for further evaluation is needed, the Senior LinkAge Line specialist should send the results of the PAS to the nursing facility and the person, as well as enter the results into MMIS. Results of any additional assessments will be shared by the lead agency with the nursing facility (if appropriate) and person. The exception in this instance is someone who is on a DD waiver. No communication should be sent to the person in these situations.
- Communication to the nursing facility and county should include both a cover letter and the output form. The person should only receive the PAS Client Letter.
| The person: | Who receives the referral? | Purpose of Referral | Note Examples |
| DD Waiver ONLY AND person is age 65+ | County of financial responsibility | County will conduct appropriate activities after PAS is entered by SLL and conduct OBRA Level II. | Client is open to DD waiver and triggers for an OBRA Level II DD screening. **Tip: On the referral letter mark that the referral is being made for waiver enrollee and OBRA Level II DD, note SLL processed the screening and action is needed. |
| DD Waiver ONLY AND person is under age 65 | County of financial responsibility AND County of nursing facility location | County will conduct appropriate activities after PAS is entered by SLL and conduct OBRA Level II. | Client is open to DD waiver, triggers for an OBRA Level II DD, and is under age 65. SLL forwarding PAS to ___ county to conduct appropriate activities and ___ county for under age 65 referral. **Tip: On the referral letter mark that the referral is being made for waiver enrollee and OBRA Level II DD, note SLL processed the screening and action is needed. |
| County will conduct 80th day assessment. | Client is open to DD waiver, triggers for an OBRA Level II DD, and is under age 65. SLL forwarding PAS to ___ county to conduct appropriate activities and ___ county for under age 65 referral. | ||
| ECS | County of residence ( COR on last screening in MMIS) | County will exit person from ECS and SLL will then enter the PAS | Client is open to ECS. Sending to county of residence, as listed in MMIS, so that ECS can be closed and an exit document entered into MMIS within 1 business day. This will allow SLL to process and enter the preadmission screening. Please notify the Senior Linkage Line specialist once the exit screening has been entered in MMIS. |
| No programs or straight MA (no MSHO, SNBC, MSC+ or waiver) | Depends on results of PAS (see rest of table). If none of these criteria are met, no other agency receives the referral. | N/A | N/A |
| LOC cannot be determined (Initial PAS or 90 Day Redeterminations) | County of person's location (At the time of submission. For PAS this is usually the county of the hospital or clinic. For 90 Day Redeterminations this is the SNF location) | County will conduct face-to-face assessment to provide final determination of Level of Care. | Client’s level of care cannot be determined. Please complete a face-to-face assessment. |
| Is under age 65 *For all PAS submitted (regardless of program status), except under 21 | County of nursing facility location | Conduct face-to-face assessment by 80th day of admission. | SLL forwarding for under 65 referral. |
| Needs OBRA Level II DD referral *At least one question is answered true in the Developmental Disabilities section | County of financial responsibility *If person is out of state send to MN CFR | County will conduct OBRA Level II screening. | Client triggers for an OBRA Level II DD screening, please complete. |
| Needs OBRA Level II MI referral *Any questions are answered true in the Mental Illness section | County of person's location (At the time of PAS submission. The county of location is filled out by the submitter in the Mental Illness section) *If person is out of state, send to county of MN SNF location | County will conduct OBRA Level II screening. | Client triggers for an OBRA Level II MI screening, please complete. |
| Needs OBRA Level II DD and MI referral | County of financial responsibility | County will conduct OBRA Level II screening. | Client triggers for both MI and DD Level II screenings, please complete. |
| MA closed, waiver opened | County of financial responsibility (DD, CAC, CADI, or BI) MCO (MSHO/MSC+ & EW) County of residence (EW or AC) | Conduct appropriate waiver activities | Client is open to ___ but MMIS shows that MA is inactive. SLL forwarding for processing. If they are no longer on programs, enter an exit document in MMIS and notify the Senior LinkAge Line. |
NOTE: When providing the information to the county, please ensure you alert them to all reasons for the referral, as well as if referrals are made to multiple lead agencies. Examples include, but are not limited to: Need for OBRA Level II DD Screening & is under the age of 65; Does not meet LOC and needs and OBRA Level II screening
Green = Managed Care ONLY Yellow = Managed Care AND Waiver Blue = Waiver ONLY Orange = Other
Keywords: OBRA, lead agency,