0105.025.15.40  Supplemental Nursing Care Explanation

Give copies of the following:

1. Medicaid and You; IM-4 Medicaid
2. Non-Emergency Medical Transportation
3. Supplemental Nursing Care; IM-4 SNC
4. Hearing Rights; IM-4 Hearings

Complete the following forms, at a minimum:

1. Application and Eligibility Statement, IM-1MA
2. Request for Direct Deposit, IM-20
3. Age Verification form (if needed and applying based on age), IM-11
4. Insurance form, IM-9 if needed
5. Referral for Social Security Number, SSN-1 if needed
6. Request for Information; IM-31A
7. If applying based on disability and Medical Review Team (MRT) decision will be required. St. Louis City has its own MRT and MRT processes. Offices outside of St. Louis City will complete and submit all documents necessary in the MRT-Processing Center Packet:
   • MRT Checklist
   • Authorization for Disclosure of Consumer Medical/Health Information (MO-650-2616) (requires applicant’s signature)
   • Social Information Summary (IM61)
   • Disability Questionnaire (IM61B)
   • Work History (IM61C)
   • Facility/Doctors List (IM61D)
   • Visual Disability Examination Report (if application includes a determination needed based on blindness) (IM68)
8. Initial Assessment and Social Assessment
9. Third Party Liability, if needed, TPL-1

Explain the following:

1. Types of facilities
2. Payment levels
3. Need for level of care determination, if applicable
4. December 1973 eligibility requirements (see 0105.020.15.50)
5. Need
6. Personal Needs check
7. QMB and SLMB
8. Medicare Buy-in
9. Social Security Numbers
10. Available services and how to access them
11. Prior Quarter Coverage