How to Fill Out the Michigan DCH-3878 OBRA Exemption Form

The Michigan DCH-3878 form is a one-page medical certification that lets a physician, physician’s assistant, or nurse practitioner document that a nursing facility resident qualifies for one of three exemptions from a full PASARR Level II evaluation: coma or persistent vegetative state, dementia without a co-occurring serious mental illness or intellectual disability, or a hospital exempted discharge expected to last fewer than 30 days. The form is only used after a DCH-3877 Level I screen has flagged a potential mental illness, intellectual disability, developmental disability, or related condition. Without a properly completed DCH-3878 in that situation, the nursing facility cannot admit or retain the person without a full Level II assessment, and Medicaid will not reimburse the facility for care provided in the interim.¹

Who Can Sign the DCH-3878

Only three types of professionals are authorized to complete, sign, and date the form: a physician, a physician’s assistant, or a nurse practitioner.¹ This is narrower than the DCH-3877 Level I screen, which registered nurses, licensed social workers, licensed professional counselors, and psychologists may also complete.²

The distinction matters because the DCH-3878 is a diagnostic certification, not a screening tool. The clinician is putting their professional judgment on the line about the diagnosis (dementia type, coma status) or expected length of stay. A social worker or RN who completed the Level I cannot also sign the exemption.

The Three Exemption Categories

The form gives exactly three grounds for skipping a Level II evaluation. Only one may be marked, and every sub-certification for that category must be met.¹

Coma or Persistent Vegetative State

The clinician certifies that the patient is currently in a coma or persistent vegetative state. It is a single statement with no sub-parts. A person in this condition cannot participate in or benefit from specialized mental health or disability services, so the full evaluation is bypassed.

Dementia

This exemption carries the most requirements. The clinician must certify all three of the following:

The patient has dementia established by clinical examination and meets all five diagnostic criteria listed on the form.
The patient does not have a primary psychiatric diagnosis of a serious mental illness.
The patient does not have an intellectual disability, developmental disability, or a related condition.

The form also asks the clinician to write in the specific type of dementia. If the resident has dementia alongside a serious mental illness diagnosis, the exemption does not apply and a Level II evaluation is required.

Hospital Exempted Discharge

This exemption covers people transferring directly from an inpatient hospital stay to a nursing facility. The clinician must certify three things: the patient is being admitted after an inpatient medical hospital stay, the patient needs nursing facility services for the same condition treated in the hospital, and the patient is likely to need fewer than 30 days of nursing care.¹

The 30-day figure comes from federal regulations. If the stay extends past 30 days, the local Community Mental Health Services Program (CMHSP) must conduct a Level II resident review within 40 calendar days of the original admission date.³ The under-30-day estimate has to be a genuine clinical judgment. Using it as a convenient way to avoid the Level II is what triggers Medicaid recovery actions later.

Filling Out the Form

The form is a one-page PDF available from the Michigan Department of Health and Human Services website. It has three sections.¹

Section 1: Instructions

Section 1 is a reference block reminding the clinician that the form is used only when a DCH-3877 has already identified a potential PASARR condition and an exemption applies. Nothing is filled in here.

Section 2: General Information

This section captures identifying information that must match the corresponding DCH-3877:

Patient’s full legal name, exactly as it appears on the DCH-3877.
Date of birth, matching the DCH-3877 entry.
Referring agency: the facility, hospital, or agency that initiated the screening.
Agency address and telephone number: full street address, city, state, and zip code.

Mismatches between the DCH-3877 and DCH-3878, such as different name spellings or dates of birth, create processing problems at the CMHSP. Check these fields against the Level I form before moving on.

Section 3: Exemption Criteria

Mark with an “X” the single exemption that applies. For coma, mark the one certification statement. For dementia, affirm all three sub-certifications and write in the specific type of dementia. For hospital exempted discharge, affirm all three conditions (inpatient hospital stay, same-condition nursing care, expected stay under 30 days).

The clinician then signs and dates the form and prints their name, credentials, and telephone number in the signature block. An unsigned or undated form is invalid, and Medicaid will not reimburse the facility on the strength of it.¹

Where to Send the Completed Form

The DCH-3878 has a three-way distribution requirement:¹

The nursing facility keeps the original in the patient’s file.
A copy is attached to the DCH-3877 and sent to the local CMHSP.
A copy goes to the patient or their legal representative.

The CMHSP copy is the one that governs compliance. It documents that the facility identified a potential PASARR condition and that a qualified clinician certified an exemption. Skipping this copy leaves no record with the mental health authority that the exemption was properly certified, and that gap is what triggers Medicaid recovery down the line.⁴

What Happens After the Form Is Filed

Once the CMHSP receives the paired DCH-3877 and DCH-3878, the local OBRA Coordinator reviews the documentation. If the exemption is properly certified, the individual may be admitted or retained without a Level II. The CMHSP keeps the forms on file for audit purposes.⁵

For hospital exempted discharges, the clock is running from day one. If the resident’s stay extends past 30 days, the nursing facility must immediately request a Level II evaluation from the CMHSP. In Michigan, the CMHSP then has 14 calendar days to complete the Level II. If the facility does not hear back within that window, state guidance recommends contacting the coordinator directly and documenting the conversation.⁶

For coma and dementia exemptions there is no automatic expiration, but a fresh Level I screen is required each year under the Annual Resident Review process. If the resident’s condition changes, for example a dementia patient develops a co-occurring serious mental illness, the exemption no longer applies and a Level II must be requested. A significant change in psychiatric condition also triggers a new Level I outside the annual cycle; waiting for the yearly review when the resident’s status has clearly shifted creates the same compliance exposure as skipping the screen entirely.

Medicaid Consequences of Getting It Wrong

Michigan ties PASARR compliance directly to Medicaid reimbursement. A nursing facility that admits someone without proper screening, or without a valid DCH-3878 exemption when one was needed, risks losing the Medicaid payments made for that resident’s care. The state has been actively recovering funds for incorrect admissions and timeliness failures since March 2003.⁶

The recovery follows a set sequence. MDHHS first determines whether the admission was handled correctly and whether the facility requested a Level II on time when one was required. Next, the department confirms whether Medicaid funds were actually paid during the period in question. If both conditions are met, MDHHS calculates the recovery amount and issues an official notice. The facility then has 30 days from receipt of that notice to appeal before collection begins.

A missing or incomplete DCH-3878 is not a paperwork nuisance. It is a direct route to having Medicaid payments clawed back for potentially months of care, which is why a reliable internal process for completing and distributing the DCH-3877 and DCH-3878 together on every admission pays for itself many times over.

1
Michigan Department of Health and Human Services. DCH-3878 Mental Illness/Intellectual/Developmental Disability/Related Condition Exemption Criteria Certification
2
State of Michigan. OBRA-PASARR
3
eCFR. 42 CFR Part 483 Subpart C – Preadmission Screening and Annual Resident Review
4
Michigan Department of Health and Human Services. DCH-3877 Preadmission Screening (PAS)/Annual Resident Review (ARR)
5
Michigan Department of Health and Human Services. OBRA – Specialized Nursing Homes
6
Michigan Department of Health and Human Services. PASARR for Nursing Homes