Georgia Medicaid PASRR Guide (2026)

Before a Georgia family member can be admitted to a Medicaid-certified nursing facility, federal law requires a screening that most families never see and never hear named. It is called Preadmission Screening and Resident Review (PASRR), and it applies to every applicant or resident of a Medicaid-certified nursing facility, regardless of how the care is paid for.1 The screening exists because Congress concluded in 1987 that too many Americans with serious mental illness or intellectual disability were being placed in nursing homes that were not equipped to treat their actual needs.

PASRR runs in two stages. A Level I screen identifies whether the applicant or resident may have serious mental illness (SMI) or intellectual disability (IID).1 If Level I is positive, a Level II evaluation determines whether the person needs nursing-facility level of care and whether the person needs Specialized Services for the underlying condition.1 In Georgia, the Department of Community Health (DCH) contracts the Level I work to Health Services Advisory Group (HSAG), and the Department of Behavioral Health and Developmental Disabilities (DBHDD) conducts Level II evaluations as the State Mental Health Authority and Intellectual Disability Authority.

This guide translates the Georgia Medicaid PASRR framework for families. It explains what PASRR is, when it applies, what each step of the Level I and Level II process looks like, what Specialized Services means, how categorical determinations and exempted hospital discharge work, what the Resident Review obligation requires, how the Olmstead v. L.C. decision reshaped PASRR in Georgia, and how to appeal a determination through the Office of State Administrative Hearings (OSAH).

In This Guide

• Key takeaways for Georgia Medicaid PASRR
• What Georgia Medicaid PASRR is and why it exists
• The Level I screen in Georgia Medicaid PASRR
• When a Level II evaluation is triggered
• Categorical determinations and exempted hospital discharge
• Specialized Services under Georgia Medicaid PASRR
• The Resident Review obligation
• Olmstead and the community-integration mandate
• DCH, HSAG, and DBHDD: the Georgia Medicaid PASRR roles
• How families navigate Georgia Medicaid PASRR
• Common failure modes and how families respond
• Appealing a Georgia Medicaid PASRR determination
• Frequently Asked Questions
• Learn More

What Georgia Medicaid PASRR is and why it exists

PASRR is a federal Medicaid requirement based on section 1919(e)(7) of the Social Security Act, with implementing rules at 42 CFR 483.100 through 483.138.1 It was created by the Nursing Home Reform Act of 1987. The statute requires every state to run a screening and review program for individuals with mental illness or intellectual disability who apply to or reside in a Medicaid-certified nursing facility.

The purpose has two prongs. First, ensure that individuals are not placed in nursing facilities when their primary needs are for mental-health or intellectual-disability services a nursing facility is not designed to provide. Second, ensure that when individuals with SMI or IID are appropriately placed for unrelated medical reasons, they receive the Specialized Services their conditions require. PASRR is not a tool for excluding people with disabilities from nursing facilities; it confirms that placement is appropriate and that services follow the resident.

The requirement applies to all individuals with mental illness or intellectual disability who apply to or reside in Medicaid-certified nursing facilities, regardless of the source of payment for the nursing-facility services.1 This is the source of considerable confusion: a privately paying resident is covered if the facility participates in Medicaid, and so is a Medicare-paying resident in a dually certified facility. The trigger is the facility's certification status, not the resident's payer source.

PASRR reaches a narrow set of facility types. It applies to nursing facilities certified to participate in Medicaid. It does not apply to intermediate care facilities for individuals with intellectual disabilities (ICF/IIDs), which have their own admission standards, or to assisted living facilities, personal care homes, residential care facilities, or group homes. The line is the facility's participation in Medicaid as a nursing facility, not the kind of care the resident receives.

The Level I screen in Georgia Medicaid PASRR

The Level I screen is the first PASRR step. The state's PASRR program must identify all individuals who are suspected of having serious mental illness or intellectual disability.1 The screen does not diagnose. It identifies whether further evaluation is warranted.

In Georgia, the Level I screen is administered by HSAG under contract with DCH and must be completed before admission. A facility cannot lawfully admit a resident without a completed Level I screen on file. The screen is typically completed by the hospital discharge planner, by a social worker at a community provider, or by the nursing facility itself. HSAG processes the screen, returns a determination, and either clears the resident for admission or refers the case for a Level II evaluation when SMI or IID indicators are present.

The Level I screen asks about psychiatric history (diagnoses such as schizophrenia, mood disorders, and other psychotic disorders that may result in chronic disability and significant functional impairment), about intellectual disability, and about other developmental disabilities causing comparable impairment. It also asks about dementia, because the federal regulations treat the two differently.

The dementia interaction is one of the most consequential and least-understood pieces of PASRR. Under the federal definition of serious mental illness at 42 CFR 483.102, a primary diagnosis of dementia is not by itself the basis for an SMI finding, so an older adult with advanced dementia who needs nursing facility care will often clear the Level I screen. The order of onset matters: a resident with a long-standing SMI diagnosis (for example, schizophrenia) who later develops dementia is screened as a person with SMI, while a resident who develops dementia without a pre-existing psychiatric history generally is not. Confirm how a specific case is screened with DBHDD, because the determination turns on documented history.

The Level I result is documented in the resident's record, and the facility cannot admit until the screen is complete. If the screen indicates a possible SMI or IID condition, the facility cannot admit without a Level II determination, except under the limited circumstances of categorical determinations and exempted hospital discharge described below.

When a Level II evaluation is triggered

When the Level I screen identifies indicators of SMI or IID, the case is referred for a Level II evaluation.1 In Georgia, Level II evaluations are conducted by DBHDD as the State Mental Health Authority (for SMI cases) and the Intellectual Disability Authority (for IID cases). The evaluation must be completed before admission, except where federal regulation explicitly permits admission first, such as exempted hospital discharges and certain categorical determinations.

The Level II evaluation makes two interrelated determinations: whether the individual needs the nursing-facility level of care, and whether the individual needs Specialized Services.1 The evaluator also considers whether a community alternative would meet the person's needs, collecting records, interviewing the resident when feasible along with family and current caregivers, and producing a written evaluation with a determination.

The evaluator must be independent of the nursing facility, so the facility cannot evaluate its own incoming resident. For SMI cases, the evaluator is typically a psychiatrist, psychologist, or other qualified mental-health professional; for IID cases, a clinical psychologist or developmental specialist. The evaluation involves a face-to-face component when the resident's condition permits, along with records review and collateral interviews.

The combination of the two determinations shapes the placement decision. A resident who needs nursing-facility services and Specialized Services may be admitted with Specialized Services attached. A resident who does not need nursing-facility services but needs Specialized Services should be diverted to a community setting where those services can be provided. A resident who needs neither should not be placed in a nursing facility at all.

DBHDD completes the Level II within the timeframe specified by federal regulation and the DCH-DBHDD memorandum of understanding, with shorter windows for hospital discharges that qualify for expedited review; verify current timeframes with DBHDD, because the operational windows are set in state agreements that change. Delays are a chronic source of complaints, because a Level II delay can keep a hospitalized patient in an acute-care bed longer than anyone benefits from.

Categorical determinations and exempted hospital discharge

Federal regulation recognizes that a full Level II evaluation in every case would produce delays that harm some residents. The rules authorize categorical determinations, which are streamlined determinations made by the state without a full individualized Level II evaluation for certain narrow categories. A separate path, the exempted hospital discharge, applies to residents transferring from a hospital under specific conditions.1

Common categories include convalescent care (a short post-hospital stay unrelated to the SMI or IID diagnosis), terminal illness, severe medical illness where Specialized Services would be clinically inappropriate, and respite care for primary caregivers. The operative list of categories, the duration limits, and the conditions on each evolve, so consult current CMS guidance, the PASRR Technical Assistance Center, or DCH PASRR policy directly rather than relying on a fixed day count.

These categorical determinations do not eliminate the screening obligation. The Level I screen is still required, and the categorical determination is documented as the state's answer to what kind of evaluation was conducted. The state retains authority to convert a categorical placement to a full Level II evaluation if circumstances change, particularly if the stay extends beyond the period the category contemplated.

The exempted hospital discharge is a separate and frequently invoked path. An individual being discharged from a hospital to a nursing facility may be admitted under a presumptive determination when the attending physician certifies that the individual is likely to require only a short-term stay for the condition treated in the hospital, with a referral for a full Level II evaluation required if the stay extends beyond the regulatory short-stay window. It is intended for the common scenario of an older adult hospitalized for a fall or stroke who needs short-term rehabilitation and is expected to return to the community. When the path is used for a resident who does have a possible SMI or IID condition, the short-stay clock is firm: if the resident remains beyond the regulatory window, the facility must refer to DBHDD for a full Level II evaluation, and facilities that fail to refer at the cutoff are out of compliance and exposed to surveyor citations and potential payment recoupment.

Specialized Services under Georgia Medicaid PASRR

Specialized Services are the services an individual with SMI or IID may need beyond what a nursing facility ordinarily provides. Federal regulation distinguishes them from nursing-facility services. Nursing-facility services are the room, board, nursing care, basic rehabilitation, and supportive services every resident receives. Specialized Services are the clinical or programmatic services targeted to the underlying condition: active treatment for an IID condition, psychiatric care for an SMI condition, and behavioral programming designed for the resident's diagnostic profile.

Where Specialized Services are required, the state must provide or arrange for them, and nursing facilities must provide mental-health or intellectual-disability services of lesser intensity to residents who need them.1 The state's responsibility does not transfer to the nursing facility. In Georgia, DBHDD typically arranges Specialized Services through its community mental-health and developmental-disability network, with services delivered to the resident at the nursing facility or, in some cases, through structured visits to community settings.

The Specialized Services obligation is one of the most frequently litigated and least consistently implemented pieces of PASRR. States have been cited for failing to deliver Specialized Services to Level II-positive residents, and several Olmstead settlements, including Georgia's 2010 Settlement Agreement, addressed the gap. For Georgia families, the practical implication is that a resident with an SMI or IID condition placed in a nursing facility for unrelated medical reasons should be receiving documented Specialized Services. If the resident is not, the family or an advocate can request a PASRR review, contact the Georgia Long-Term Care Ombudsman, or contact Disability Rights Georgia.

The Resident Review obligation

PASRR is not only a pre-admission screening. The PASRR regulations require a Resident Review whenever a nursing-facility resident experiences a significant change in physical or mental condition. The Resident Review is not the routine Minimum Data Set (MDS) assessment every resident receives quarterly. It is a separate, condition-triggered review that determines whether the resident's new condition warrants a fresh Level I screen, a fresh Level II evaluation, a change in Specialized Services, or a change in placement.

A significant change in condition includes events such as a new psychiatric diagnosis, a new behavioral manifestation suggesting an underlying psychiatric or developmental condition, a sudden onset of psychotic symptoms, or any change that would have triggered a Level II evaluation had it been present at admission. The nursing facility must initiate the Resident Review by referring the resident to HSAG for a fresh Level I screen, with the same downstream process applying as for pre-admission cases.

The Resident Review often fails in practice. Facilities may interpret a significant change in condition narrowly, focusing on medical changes that affect the MDS rather than psychiatric or developmental changes that warrant PASRR re-screening. Family members and the Long-Term Care Ombudsman are frequently the parties who identify a missed Resident Review trigger. The Ombudsman Program can request a Resident Review on a resident's behalf, and Disability Rights Georgia has used Resident Review failures as the basis for advocacy intervention.

Olmstead and the community-integration mandate

The Supreme Court's decision in Olmstead v. L.C. shapes the legal landscape in which PASRR operates. Olmstead held that under Title II of the Americans with Disabilities Act, public entities must administer services in the most integrated setting appropriate to the needs of individuals with disabilities. The decision did not invalidate institutional placement, but it requires states to justify institutional placement when a community alternative would meet the individual's needs and the individual does not oppose community placement.

For PASRR, Olmstead has two consequences. First, the Level II evaluation must consider community alternatives, not only the appropriateness of nursing-facility placement. If a community placement with appropriate supports would meet the resident's needs and the resident does not oppose it, that placement should be offered. Second, the state's obligation to deliver Specialized Services intersects with its Olmstead obligation: a resident receiving Specialized Services in a nursing facility may be entitled to equivalent services in an appropriate community setting.

Georgia's 2010 USDOJ Settlement Agreement addressed nursing-facility placement of individuals with disabilities. The settlement required Georgia to expand community-based services, reduce nursing-facility placement of individuals with intellectual and developmental disabilities, and improve coordination between Level II determinations and community placement options. The state operates an Olmstead Hotline for individuals to request community placement when they believe they have been inappropriately institutionalized or are at risk of it; verify the current Olmstead Hotline contact details on the DBHDD website.

DCH, HSAG, and DBHDD: the Georgia Medicaid PASRR roles

Three Georgia entities operate the PASRR program. Understanding their respective roles is essential for any family or advocate navigating the process. The current operational structure is summarized below; confirm contact details and current responsibilities on each agency's website.

DCH is Georgia's Medicaid agency. It holds the federal PASRR program responsibility, administers nursing-facility certification, contracts with HSAG as the Level I administrator, and maintains the memorandum of understanding with DBHDD that allocates Level II responsibilities. DCH retains overall program responsibility and pays for PASRR administration. Verify member-services contact details on dch.georgia.gov.

HSAG is the DCH-contracted Level I administrator. It receives Level I screen submissions from hospitals, community providers, and nursing facilities, processes them, returns determinations, and refers qualifying cases to DBHDD for Level II evaluation. Verify HSAG's current Georgia PASRR line before submitting a screen or status check.

DBHDD is Georgia's State Mental Health Authority and Intellectual Disability Authority. It conducts Level II evaluations through its contracted evaluator network, oversees Specialized Services delivery for residents with positive determinations, coordinates community placement options, and operates the Olmstead Hotline. Verify DBHDD intake numbers, the office that handles PASRR program inquiries, and the Olmstead Hotline number on the DBHDD website.

Federal regulation also places obligations directly on nursing facilities. A facility cannot admit a resident without a completed Level I screen, must refer for Level II evaluation when the Level I indicates a concern, must implement the care plan including Specialized Services when a Level II requires them, and must identify and refer for Resident Review when a resident's condition changes significantly.1 CMS surveyors cite facilities for PASRR non-compliance during surveys and complaint investigations; the Georgia State Survey Agency conducts the surveys on CMS's behalf. Citations can result in plans of correction, civil money penalties, denial of payment for new admissions, and, in serious cases, termination of the Medicaid provider agreement.

How families navigate Georgia Medicaid PASRR

The PASRR process is largely invisible to families until it goes wrong. Most never see the Level I screen, hear whether a Level II was triggered, or learn that a resident has a right to a community placement when a Level II identifies a community alternative as appropriate. The three scenarios below are hypothetical, illustrative composites, not real cases; they show how PASRR shapes nursing-facility placement decisions in Georgia.

Jamil, 32, Columbus: an intellectual-disability placement diverted to the community

Jamil has moderate intellectual disability and has lived with his mother his whole life. She has been diagnosed with terminal cancer and can no longer care for him. Unable to find a same-day community placement, a hospital social worker refers Jamil to a Muscogee County nursing facility and submits a Level I screen. The screen identifies his intellectual disability, and HSAG refers him to DBHDD. The developmental specialist who conducts the Level II concludes that Jamil does not need nursing-facility-level services: he is medically stable and ambulatory, but he needs extensive supports and structured programming. The evaluator determines that a community placement under the state's home and community-based Medicaid waiver for people with intellectual and developmental disabilities would be appropriate and that Jamil opposes nursing-facility placement. DBHDD's regional office coordinates an emergency placement, and within days Jamil is transitioned directly to a host-home provider without ever being admitted. The Level II determination opened a community pathway that would not have existed without PASRR.

Diana, 84, rural Georgia: a Resident Review for a change in condition

Diana is a long-term nursing-facility resident admitted three years ago after a hip fracture. Her Level I screen at admission was negative. Over the past four months, the facility's medical director has noted persistent paranoid beliefs, occasional hallucinations, and behavioral disturbances that are not typical for her dementia trajectory and that suggest a previously undiagnosed psychiatric condition. Under the PASRR Resident Review requirement, this constitutes a significant change in condition. The facility refers Diana to HSAG for a fresh Level I screen, which now identifies the new psychiatric symptoms, and HSAG refers to DBHDD. The Level II evaluator confirms a psychotic disorder warranting psychiatric care and determines that Diana now needs Specialized Services that were not required at admission. DBHDD coordinates with a contracted geriatric psychiatrist to provide ongoing medication management at the facility. The Resident Review ensured Diana's emergent psychiatric condition received targeted treatment rather than being managed only with non-specific sedating medications.

Olivia's father, 70, Atlanta: an Olmstead-grounded nursing facility diversion

Olivia's father has long-standing schizophrenia and has lived in his own apartment for years with weekly community mental-health visits. After a hospitalization for a complicated urinary tract infection that worsened his psychiatric symptoms, the discharge planner prepares to transfer him to a nursing facility, uncertain whether his community supports can handle his return. Olivia asks for a PASRR Level II evaluation before any transfer. The Level I screen identifies his SMI history and triggers a Level II. The DBHDD evaluator interviews him and his community mental-health team, concludes that he does not need nursing-facility services, and finds that with intensified community supports he could return to his apartment, which he strongly prefers. Combined with the Olmstead community-integration mandate, the determination leads DBHDD to coordinate a transition plan that returns him to his apartment with an Assertive Community Treatment (ACT) team. The community alternative is not always available, and DBHDD capacity constraints are real, but the Level II is the trigger that opens the inquiry.

Common failure modes and how families respond

PASRR's effectiveness depends on every actor in the chain doing its job, and the process fails in several recognizable patterns.

Missed Level I screens at admission

A facility that admits a resident without completing the Level I screen is in clear violation of federal regulation, and this is the most fundamental failure. Families typically discover it only when reviewing the resident's medical record. The Georgia Long-Term Care Ombudsman and the State Survey Agency are the primary mechanisms for reporting and correcting missed screens.

Level II referrals that should have been made but were not

A Level I screen may identify SMI or IID indicators but the case may not be referred to DBHDD, or the referral may be made but never acted on. The family's best protection is to request, in writing, copies of any Level I and Level II screening documents from the facility, and to follow up with HSAG and DBHDD directly.

Specialized Services that were ordered but never delivered

Olmstead settlements across the country have repeatedly targeted the population whose Specialized Services were ordered but never delivered. If a Georgia family member with IID is in a nursing facility, families should ask explicitly whether Specialized Services have been arranged, request documentation, and contact Disability Rights Georgia or the Georgia Advocacy Office if the services are not being delivered.

Missed Resident Reviews when a resident's condition changes

These are common because the facility may interpret significant change narrowly. Family members are often the first to notice psychiatric or behavioral changes, and a written request to the facility for a Resident Review (with a copy to HSAG) creates a documented basis for triggering the process.

Community alternatives the Level II identifies but the state does not arrange

DBHDD capacity constraints may delay or prevent a placement the Level II found appropriate. The Olmstead Hotline is the state's mechanism for escalating these cases, and legal-services organizations such as the Georgia Legal Services Program and the Atlanta Legal Aid Society can support families when administrative escalation has not produced a placement.

Appealing a Georgia Medicaid PASRR determination

A PASRR determination can be appealed. The resident or applicant has the right to appeal a Level II determination through the state fair-hearing process. In Georgia, PASRR appeals are heard through the Office of State Administrative Hearings (OSAH), with appeal rights set out in the resident's notice of determination. The notice is supposed to explain the determination, the basis for it, the right to appeal, and the deadline for filing; consult the notice and the OSAH website for the operative filing deadline.

The grounds for appeal include disagreement with the Level II evaluator's clinical determination, disagreement with the placement recommendation, disagreement with the Specialized Services determination, and procedural challenges such as a screening conducted without proper notice. Families should keep copies of all PASRR documentation, including the Level I screen, the Level II evaluation report, the determination notice, and any related correspondence.

Appeals are heard by an OSAH administrative law judge. The resident may be represented by an attorney, a family member, an Ombudsman, a Disability Rights Georgia advocate, or another representative. Beyond the formal appeal, families have other escalation paths: complaints to the State Survey Agency can prompt surveyor investigations of facility-level compliance, and complaints to the HHS Office for Civil Rights Region IV are appropriate when the underlying issue involves discrimination or violations of the ADA.

Key Georgia Medicaid PASRR contacts

For current phone numbers and contact details, consult the official websites below.

Learn More

Find personalized help navigating Georgia Medicaid PASRR at brevy.com.

The information on Brevy.com is for educational purposes only and is not a substitute for professional legal, financial, or medical advice. Rules vary by state and program and change frequently. Always verify with the relevant agency or a qualified professional. Brevy is not a law firm, financial advisor, or healthcare provider.