0815.015.00 CLAIMANTS CURRENTLY RECEIVING MEDICAL ASSISTANCE OR SNC TO VENDOR

When a participant currently receiving MHABD enters a MO HealthNet (MHN) certified bed (T19) in a nursing facility (SNF), an institution for the developmentally disabled (IMR), or a state mental hospital (MHC), payments may be made directly to the facility that is providing care to the individual.

A MO HealthNet Eligibility Review Information form (FA-402) or a Reinvestigation-Eligibility Statement form (IM-2D) is not required to transfer an active MHABD participant to vendor. When the annual review is due at the same time that a change to vendor is reported, complete the review as a separate action from the change to vendor care. Do not delay the change to vendor level of care, while waiting to complete an annual review.

When an individual is only included (ZP) in an active MHABD Eligibility Unit an Add a Person Request must be completed before eligibility for vendor benefits for the individual can be determined.

When a MO HealthNet participant enters a nursing facility, eligibility for vendor benefits must be explored. Vendor benefits must be authorized as soon as all necessary information, including a level of care determination, is received. See Section 0815.015.10 Tracking MHABD to Vendor Requests.

Complete the following steps within two working days of notification of the placement:

• Change the individual's address.
  • Single Person: The new facility address is added on the Eligibility Unit Transfer screen (EUTRAN or FM12) along with the living arrangement code NURSING HOME/RESIDENTIAL CARE (NH).
  • Couple case where the community spouse is receiving benefits or is the payee for an active EU receiving benefits and the community spouse remains at the residential address: Add the institutionalized spouse's new facility address on the individual's Person Detail screen (PRSNDTL or FM0I) if the participant/family elect to have all mail sent to the facility.
  • Couple case where the community spouse is not receiving benefits: The new facility address is added on the Eligibility Unit Transfer screen (EUTRAN or FM12) along with the living arrangement code NURSING HOME/RESIDENTIAL CARE (NH). Add the community spouse's address on the Person Detail screen (PRSNDTL or FM0I) if the participant/family requests that mail to go to the community spouse's address instead of the facility address.
• On the comment screen accessed from the Eligibility Unit Member Role screen (EUMEMROL or FM3Z) document the reported change in living arrangements. Include the date of the report, who reported the change or how it became known, the date the change occurred, and the action that was taken.
• Enter the facility details and placement details on the Facility Placement and Information Details screen from the Facility Placement information screen (FACPLACE or FMJ4). Comments must be entered from this screen to document verification of the placement. Refer to the FAMIS user guide Facility and Placement Information Details.

  NOTE: If a participant is receiving a Supplemental Nursing Care (SNC) cash grant, the Facility and Placement Information Details screen (FACPLACE or FMJ4) must be updated with the change from the SNC facility to the vendor facility. The Eligibility Specialist must complete an eligibility determination (EDRES) in FAMIS and authorize the action to end the cash grant within two working days of notification of change in placement. The vendor determination will pend for verification of the Level of Care certification from COMRU. If a participant receives a cash grant for a month they are in a vendor facility, the cash grant and personal needs payment must be included as unearned income in the surplus determination.

Other steps to determine vendor eligibility may include:

• For a couple case, a Division of Assets (DIVISION or FMWR) must be completed. Refer to the FAMIS user guide DIVISION OF ASSETS.
• For individuals with dependents, explore any allotments to the community spouse and other dependents in the home or outside the home. Refer to the FAMIS user guide Allotment Information Screen. An add-a-person action on the Application Request (Request, FM0G) screen may be needed to add the dependent to the EU.

Complete an Eligibility Determination (EDRES) to determine eligibility for vendor benefits in FAMIS as soon as:

• the participant is medically certified for NF, IMR, or MHC; (See Section 0815.020.00)
• pre-admission screening (DA-124C) requirements are met for NF cases; (See Section 0815.025.00)

  Note: Review the DA-124 Inquiry Report screen in FAMIS from the Facility and Placement Information Details screen press F14=I124.

• the participant meets age requirements (MHC); (See Section 0815.055.00);
• the surplus (See Section 0815.030.00), and when necessary the allotment (ALLOT or FMJ6) (See Section 0815.030.10.10) can be determined; AND
• when necessary a transfer of property (SELTRANS or FMWL) penalty period has been determined. (See Section 1040.000.00). Vendor benefits will not be recommended by FAMIS when a penalty period for transfer of property has not been completed. However the individual may be eligible for MHABD spenddown/non-spenddown.

  NOTE: Always review the Budget Summary screen prior to authorizing a case action in FAMIS. From the MHABD Action Authorization screen (FMD9) use F16= MHABD to view the MHABD Assistance Group Summary screen. Select the coverage type and use F16= AGBUDSUMM to view the Adult MO HealthNet Budget Summary screen press F17=INCSUM to view the Income Summary Detail screen and F18=EXPSUM to view the Expense Summary Detail screen to ensure all countable income and expenses are included in the budget.

  NOTE: Worker Initiated Budget Calculations (WIBCA) may need to be completed to authorize vendor benefits for an active MHABD participant who enters a vendor facility. WIBCAs will need to be completed if the vendor benefits are not authorized in the same month the change is reported. WIBCA will not be entered for months prior to the date the change was reported. From the Select Worker Initiated Budget Calculation Area screen (SELWIBCA or FMXH) press F14=ADDWIBCA. If a participant enters the vendor home after the first day of the month, or leaves the vendor home before the last day of the month multiple WIBCAs will need to be completed. The WIBCAs must be done to show the appropriate coverage type for the days when the participant was eligible for VEND VENDOR NURSING CARE, and for the days either prior to entering and/or after leaving the facility when the participant would be eligible for another coverage type such as SPNDN MA SPENDDOWN/NON-SPENDDOWN. Review the Medicaid Category History screen (MEDHIST or FM4L) to determine if WIBCAs were authorized appropriately to provide coverage to the participant for the entire month.

  All WIBCA entries must have comments supporting a valid reason for the WIBCA.

0815.015.05 Claimant Returns to Vendor Facility

If a participant returns to the vendor facility from a non-vendor situation within sixty calendar days, a new DA-124A/B and COMRU level of care determination is not required unless the participant is not currently certified for the appropriate level of care.

0815.015.10 Tracking MA and SNC to Vendor Requests

Timeliness of the decision for vendor requests is critical. The participant, the nursing facility, and family members are relying on a prompt decision.

Because no application request is entered in FAMIS for an active MHABD participant who enters a nursing facility, institution for the developmentally disabled or state mental hospital, the vendor request is not tracked by FAMIS. The Eligibility Specialist is required to monitor the case to ensure that all actions are completed promptly.

See Section 0815.015.00 PARTICIPANTS Currently Receiving MHABD to Vendor above.

Within two working days of notification of the placement in a facility the Eligibility Specialist must:

• Change the individual's address
• Document the reported change in living arrangements on the comment screen accessed from the Eligibility Unit Member Role screen (EUMEMROL or FM3Z);
• Enter the facility details and placement details on the Facility Placement and Information Details screen (FACPLACE or FMJ4) and, if needed, complete an eligibility determination and authorize the action to stop SNC cash payments; and
• Set Reminders in FAMIS to track pending actions:
  • no more than 30 days from the date of entry into the facility to determine if the DA-124 certification is available on the DA-124 Inquiry Report screen and if the vendor eligibility determination can be completed, if not;
  • at 10 days intervals until the information is available and the eligibility determination for vendor benefits is completed.