0815.005.00 Eligibility for Vendor Payments

Vendor payment may only be made in behalf of MO HealthNet for the Aged, Blind, and Disabled (MHABD) participants who meet the following requirements:

• Have received an initial assessment (DA-124 A/B) and
  • have been medically certified for NF or IMR level of care

    OR

  • are age 65 or older or under age 21and medically certified for MHC level of care.

    Note:  An individual who is certified for MHC level of care when s/he is under the age of 21 may continue to qualify for vendor payment until age 22.

• If certified for NF level of care and entering a nursing facility, have received a preadmission screening (DA-124C).

  NOTE: Review the DA-124 Inquiry Report screen in FAMIS from the Facility and Placement Information Details screen (F14=I124). See the FAMIS User Guide FACILITY AND PLACEMENT INFORMATION DETAILS.

• Qualify for MHABD based on December 1973 eligibility requirements, or as a child under age 18 based on MHF or MHK criteria.
• Reside in a MHN certified bed (T19) if in a Missouri nursing facility, or a MHN certified bed if (T19) if in a facility out of state.

A surplus determination must be made to determine the portion of the eligible participant's income which is available to pay towards the cost of their care.

0815.005.05 December 1973 Eligibility Requirements

To be eligible for MHABD Vendor, an adult (age 18 and older) applicant or participant must meet the December, 1973 eligibility requirements for Old Age Assistance (OAA), Permanent and Total Disability (PTD), or Aid to the Blind (AB). The determination of eligibility is always based on whichever eligibility factors in effect in December 1973 best meets the applicant's or participant's situation. These eligibility factors are explained in manual Section 1000.000.00.

When December 1973 eligibility is based on Permanent and Total Disability (PTD) or Aid to the Blind (AB) requirements, additional medical information may be required. If MHABD Vendor eligibility is based on PTD requirements, verification of disability must be obtained. See Section 1060.005.00. If a Medical Review Team's (MRT) decision is required, obtain medical information and Medical Report Including Physician's Certification/Disability Evaluation, form IM-60A (if available), Social Information Summary, formIM-61, and Disability Questionnaire, form IM-61B, to establish disability. Submit this information to MRT for their determination while waiting for the level of care decision from COMRU.

If MHABD vendor eligibility is based on AB requirements, verification of visual impairment must be obtained. See Section 1055.015.00 . Obtain the Visual Disability Examination Report, form IM-68, to establish eligibility based on visual impairment. Submit this information to the State Supervising Ophthalmologist while waiting for the level of care decision from COMRU.

0815.005.10 MO HealthNet Certified Beds in Nursing Facilities

Nursing facilities (SNF) may designate some or all of their beds as MO HealthNet (MHN) certified beds (T19). This designation means that the facility must accept vendor payments for the individual assigned to that bed.

In a nursing facility with all MHN certified beds, vendor payments MUST be given to eligible participants. Supplemental Nursing Care (SNC) cash payments cannot be made to participants in a nursing facility where all beds are MHN certified.

In a nursing facility with only some MHN certified beds, SNC cash payments cannot be given to an individual in a MHN certified bed. Vendor benefits must be authorized if the individual is eligible and in a MHN certified bed, or at the time they are placed in a certified bed. However, if the eligible individual is not in a MHN certified bed and is not going to be transferred to one, approve for SNC even if there is an unoccupied MHN certified bed in the facility. See Section 0600.000.00 for information on SNC. Accept the statement of nursing home personnel regarding the individual's placement in a MHN certified bed or a non-certified bed.

If the nursing facility places the individual in a Medicare certified bed (T18) and the facility states it will bill MO HealthNet for coinsurance and deductibles only, the individual should be treated as if s/he is in a MHN certified bed.