August 28, 2026
4:19 am

What Is a PASRR Screening?

A PASRR screening is the federally required review that every person must go through before being admitted to a Medicaid-certified nursing facility, to identify whether that person has a serious mental illness or an intellectual or developmental disability and, if so, whether a nursing home is the right setting for them at all. The acronym stands for Preadmission Screening and Resident Review. It applies to everyone entering a Medicaid-certified facility, not only to people who are on Medicaid, which is the single detail families most often get wrong.

The screen exists because of the Nursing Home Reform Act, enacted as part of the Omnibus Budget Reconciliation Act of 1987, and it is spelled out in the federal Medicaid regulations at 42 CFR Part 483, Subparts C and E. Congress passed it after decades in which state psychiatric hospitals discharged residents directly into nursing homes that had no ability to treat them. PASRR is the gate that was built to stop that from happening quietly.

In practice you will meet PASRR as a form a hospital discharge planner, a facility admissions coordinator, or a case manager hands you on a very short timeline, usually while a hospital is pushing for a bed. It is worth understanding what the form does and, just as importantly, what it does not do, because three other documents in the same admission packet are routinely confused with it.

In This Article

Level I and Level II: The Two Halves of the Screen
PASRR Is Not a Level of Care Determination
PASRR Is Not the MDS Assessment
PASRR Is Not the Admission Agreement, and It Is Not the Care Plan
The Exemptions and Short-Stay Rules Worth Knowing
What PASRR Does and Does Not Do to a Life Insurance Policy
Frequently Asked Questions

Level I and Level II: The Two Halves of the Screen

Level I is the short screen. It is completed for every single applicant to a Medicaid-certified nursing facility and asks whether there is any indication of a serious mental illness, an intellectual disability, or a related condition such as cerebral palsy or autism. It is usually one or two pages, often completed by hospital discharge staff, and in most states it is submitted electronically to a state contractor.

If Level I is negative, admission proceeds and nothing further happens. If Level I flags a possible condition, a Level II evaluation is triggered. Level II is a genuine clinical assessment carried out by, or on behalf of, the state mental health authority or the state intellectual disability authority. It answers two separate questions: does this person need nursing facility level of care, and does this person need specialized services for their mental illness or disability that the facility would have to arrange.

The federal rule at 42 CFR 483.112 sets a real deadline: the state authority must complete Level II determinations within an annual average of seven to nine working days from referral. That is an average measured across the state program, not a personal guarantee, but it is a benchmark you can hold a state contractor to when an admission is stuck. Ask the discharge planner who the state PASRR contractor is and on what date the Level II referral was actually transmitted, because a referral that was never sent is a common cause of delay.

The outcome of Level II is a written determination letter. Keep a copy. It is the document that decides whether the facility owes the resident specialized services, and it becomes relevant again at every annual review.

PASRR Is Not a Level of Care Determination

This is the boundary that costs families the most time. A nursing facility level of care determination asks a purely functional question: is this person impaired enough in activities of daily living, cognition, or medical need to qualify for institutional care under this state’s criteria. It is the gate for Medicaid payment of nursing home care and for most home and community based waiver programs.

PASRR asks a different question: given this person’s mental illness or disability, is a nursing facility the appropriate placement, and what specialized services are owed. A person can pass level of care and still receive a PASRR determination that a nursing home is not appropriate. A person can also clear PASRR entirely and be denied on level of care.

The two reviews are run by different offices, on different timelines, using different forms, and a denial on one tells you nothing about the other. If an admission is blocked, the first question to ask is which of the two determinations is the problem. See how the level of care determination works for the functional half of the picture.

One more distinction: level of care is about Medicaid eligibility for a service. PASRR applies regardless of who is paying. A private-pay resident entering a Medicaid-certified building still gets a Level I screen, and that surprises almost every family that is writing its own checks.

PASRR Is Not the MDS Assessment

The Minimum Data Set is the standardized clinical assessment that certified nursing facilities complete on every resident after admission and at set intervals afterward. It feeds quality measures, the CMS Care Compare star ratings, and in Medicare-covered stays it feeds payment. PASRR happens before admission. The MDS happens after.

They do interact. The identification section of the MDS records the PASRR Level II determination, and a Level II finding of a serious mental illness should be visible there. If the MDS says no PASRR condition and your family member has a Level II letter saying otherwise, that mismatch is worth raising with the director of nursing in writing, because it can cause specialized services to simply never be delivered.

The Resident Review half of PASRR is the piece that carries forward after admission. If a resident’s condition changes significantly, the facility is required to refer for a Resident Review. A new dementia diagnosis, a psychiatric hospitalization, or a marked change in behavior are the usual triggers. Families rarely know they can ask for one. You can, and you should put the request in writing so it lands in the chart. Read more about what the MDS assessment covers so you can tell the two documents apart when you review the file.

Document	Question it answers	Who runs it	When
PASRR Level I	Any indication of serious mental illness or intellectual disability?	Hospital or facility staff, filed with the state	Before admission, every applicant
PASRR Level II	Is a nursing facility appropriate, and are specialized services owed?	State mental health or intellectual disability authority	Annual average of 7 to 9 working days after referral
Level of care determination	Is this person functionally impaired enough to qualify?	State Medicaid agency or its assessor	Before Medicaid pays for the stay
MDS assessment	Clinical baseline and ongoing status	The nursing facility	After admission and at set intervals
Admission agreement	Payment, bed hold, discharge, arbitration	The facility	At admission, and it is a binding contract

PASRR Is Not the Admission Agreement, and It Is Not the Care Plan

The admission agreement is a contract between the resident and the facility. It covers payment, bed hold, discharge, arbitration clauses, and the responsible party language that families should read very carefully before signing anything. PASRR is a regulatory screen with no contractual content at all. Signing a PASRR form does not obligate anyone to pay anything, and it does not make a family member financially responsible for the bill.

The plan of care is the facility’s clinical roadmap, built after the comprehensive assessment, describing goals and interventions. Federal rules require a baseline care plan within 48 hours of admission and a comprehensive person-centered care plan within seven days of completing the comprehensive assessment. PASRR sits upstream of all of that.

Where they connect: if Level II found that specialized services are needed, those services are supposed to appear in the care plan, and the state, not the nursing facility, is generally responsible for arranging and paying for them. If a Level II determination says specialized services are owed and the care plan is silent about them, that gap belongs on the agenda at the next care plan meeting. If it is still not fixed, the state long-term care ombudsman is the free, independent office whose job is exactly this.

The Exemptions and Short-Stay Rules Worth Knowing

Federal regulation allows a narrow exemption for a person admitted directly from a hospital after treatment for the same condition, where the attending physician certifies that the nursing facility stay is expected to last no more than 30 days. That is the exempted hospital discharge, and it is why a short rehab stay after a hip fracture often moves without a Level II evaluation.

The trap is what happens on day 31. If the stay extends past the certified period, the exemption ends and a Level II evaluation is required. Families who assumed the paperwork was finished sometimes find the admission retroactively in question. If a rehab stay is running long, ask the facility directly, in writing, whether a PASRR referral has been made.

There are also categorical determinations in many states for conditions such as terminal illness, severe medical illness, or coma, where the state authority has pre-approved a streamlined outcome. These vary state by state, as do the names. The tool may be called PASRR, PASARR, or a state-specific name, and it may be administered by a private contractor rather than the agency itself.

As of 2026 the underlying federal framework has not changed, but state forms, contractors and turnaround times change frequently. Confirm the current process with your state Medicaid agency or with a State Health Insurance Assistance Program counselor before you rely on any specific timeline. Your local Area Agency on Aging can usually name the current contractor in one phone call.

What PASRR Does and Does Not Do to a Life Insurance Policy

Directly, nothing. A PASRR screening is a clinical and regulatory review. It does not touch the ownership, the beneficiary, the cash value, or the premium of any life insurance policy, and no one involved in a PASRR determination has any authority over an insurance contract.

Indirectly it matters a great deal, because PASRR usually appears at the exact moment a household is crossing into long-term care, and the Medicaid asset question arrives right behind it. That is when an in-force policy suddenly becomes financially relevant. Most state Medicaid programs treat the cash surrender value of a permanent policy as a countable resource once the total face value of all policies on one person exceeds a small threshold, and that can be the difference between an approval and a denial.

What families do next varies, and the honest answer is that there is no single right move. Some surrender the policy. Some reduce it to paid-up coverage. Some assign a small policy to an irrevocable funeral trust. Some sell it in the secondary market. And some correctly do nothing at all, because a small burial policy already inside the exclusion is better left alone. The starting point is understanding how life insurance is counted as a Medicaid asset, then working the numbers with an elder law attorney licensed in your state before any irreversible step.

Pine Lake Legacy does not purchase policies and does not give legal, tax, or Medicaid eligibility advice. What we provide is a free policy review that tells you what an in-force policy is actually worth in the current market, so you and your attorney are working from a real number instead of a guess. Send the policy cover page or call (732) 978-9575.

Frequently Asked Questions

Does PASRR apply if we are paying privately?

Yes. The screen applies to any admission to a nursing facility certified for Medicaid, regardless of who pays the bill. Private-pay families are frequently surprised by this. If the building participates in Medicaid at all, a Level I screen is required for every applicant, and a positive Level I triggers a Level II evaluation the same way it would for anyone else.

Can a PASRR determination block an admission?

It can. A Level II evaluation can conclude that a nursing facility is not the appropriate setting, which stops that admission. It can also conclude placement is appropriate but that specialized services are owed. Either outcome can be appealed through the state Medicaid fair hearing process, and the determination letter should state the deadline for requesting one.

How long is a Level II evaluation supposed to take?

Federal regulation at 42 CFR 483.112 requires the state authority to complete Level II determinations within an annual average of seven to nine working days from referral. That is a program-wide average rather than a personal deadline, but it is a fair benchmark. If an admission is stalled, confirm the exact date the referral was transmitted to the state contractor.

What happens if a rehab stay goes past 30 days?

The exempted hospital discharge only covers a stay the physician certified as lasting 30 days or less. If the stay runs longer, the exemption lapses and a Level II referral is required. Ask the facility in writing whether a referral has been made once it is clear the stay is extending, rather than assuming the paperwork is closed.

Does a PASRR screening affect my life insurance?

No. It has no effect on ownership, beneficiaries, cash value, or premiums, and nobody involved in the screening has authority over an insurance contract. What follows a nursing home admission often does affect a policy, because Medicaid eligibility counts cash surrender value as a resource. That is a separate conversation to have with an elder law attorney.

Who can tell me my state’s PASRR process?

Start with the state Medicaid agency, which either runs PASRR directly or names the contractor that does. Your local Area Agency on Aging and a State Health Insurance Assistance Program counselor can usually identify the right office in one call. Ask specifically for the current form version and the referral submission method, since both change from year to year.

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