0815.035.00 Effective Date of Vendor Coverage for Claimants in a Nursing Facility

Eligibility dates for MO HealthNet vendor coverage for applicants or participants entering a MO HealthNet certified bed in a nursing facility may be affected by the preadmission screening process. See Section 0815.025.05. Vendor eligibility cannot be approved until the results of the preadmission screening (DA-124), initial assessment and medical certification of level of care, and Level II screening notification (DA-625), if required, are received by the FSD office.

0815.035.05 Effective Date of Vendor Coverage for Applicant or Participant in a Nursing Facility When No Level II Screening is Required

If a Level II screening is not required (See Section 0815.025.05), vendor eligibility begins with the latest of the following dates:

Note: The applicant may be eligible for MHABD spend down or non-spend down from the first day of the prior quarter (third month prior to the month of application) to the date s/he entered the nursing facility. See Section 0815.050.00.

EXAMPLE: Ms. W. was admitted to a nursing facility on March 18. She applied for vendor benefits on March 21. COMRU certified Ms. W. for NF (nursing facility) level of care. No Level II screening was required, because Ms. W. was not suspected of MR, MI or DD. The eligibility specialist completed the eligibility determination on April 21. Ms. W. was found to be eligible on all factors as of the date of admission. The eligibility specialist enters the level of care determination on the Facility and Placement Information Details (FACPLACE or FMJ4) screen in FAMIS, completes an eligibility determination (EDRES) and authorizes the actions to approve the spend down/non-spend down and vendor benefits. If Ms. W requested prior quarter coverage and is eligible on all factors during the prior quarter months, she should be approved for prior quarter spend down/non-spend down as of December 1. She would have a partial month of coverage as spend down or non-spend down from March 1 – 17. The beginning date of vendor eligibility is March 18, the date she entered the nursing facility. WIBCAs for vendor coverage may be necessary if she was approved for spend down or non-spend down prior to vendor approval.

The effective date of the surplus is April 1, because Ms. W. was not in the facility on the first day of March.

If all eligibility factors and verifications except the DA-124 A/B level of care are entered, the eligibility specialist should complete the eligibility determination (EDRES) for all other MHABD programs. If the eligibility specialist does not make the eligibility determination within 5 days, FAMIS will act to approve or reject the application based on the information entered. Review the MO HealthNet Category History (MEDHIST) screen in FAMIS to confirm the dates of coverage and correct eligibility.

0815.035.10 Effective Date of Vendor Coverage for Applicant or Participant in a Nursing Facility When Level II Screening is Required and Applicant or Participant is not found to be MR, MI or DD

If a Level II screening is required (See Section 0815.025.05), but the applicant or participant is not found to be MR, MI or DD, the begin date for vendor is the same as above (0815.035.05)

NOTE: The applicant may be eligible for MHABD spend down or non-spend down from the first day of the prior quarter (third month prior to the month of application) to the date s/he entered the nursing facility. See Section 0815.050.00.

EXAMPLE: Mr. Z. was admitted to the nursing facility on June 5. He applied for MHABD on June 7. The DA-124C indicated the need for a Level II screening. COMRU certified Mr. Z. for NF level of care effective June 5. The Level II screening was completed by DMH showing that Mr. Z. was not MR, MI or DD. The eligibility specialist completed the eligibility determination on June 18. Mr. Z. was found to be eligible on all factors as of the date of admission. The eligibility specialist enters the level of care determination on the Facility and Placement Information Details (FACPLACE or FMJ4)) screen in FAMIS, completes an eligibility determination (EDRES) and authorizes the actions to approve the spend down/non-spend down and vendor benefits. If Mr. Z is eligible on all factors during the prior quarter months, he may be approved for prior quarter spend down/non-spend down as of March 1. He would have a partial month of coverage as spend down or non-spend down from June 1 - 4. The beginning date of vendor eligibility is June 5, the date he entered the nursing facility. WIBCAs for vendor may be necessary if approved for spend down or non-spend down prior to vendor approval. The effective date of the surplus is July 1, because Mr. Z was not in the facility on the first day of June.

0815.035.15 Effective Date of Vendor Coverage for Applicant or Participant in a Nursing Facility When Level II Screening is Required and the Applicant or Participant is found to be MR, MI or DD

If a Level II screening is required (See Section 0815.025.05), and the applicant or participant is found to be MR, MI or DD, vendor eligibility begins with the latest of the following dates:

EXAMPLE: Mr. V. was admitted to the nursing facility on August 12. He applied for vendor benefits on the same date. The DA-124C indicated the need for a level II screening. COMRU received the forms on August 16 and entered the information on the DA-124 screen on August 17. COMRU certified Mr. V. or NF level of care. The level II screening was completed by DMH on August 20. The eligibility specialist received the DA-625 on August 23, showing that Mr. V. was MI, but that his needs could be met at the nursing facility in which he was residing. Because the applicant was found to be MI, the begin date of vendor eligibility cannot be before the level II screening was completed by DMH. If Mr. V. was otherwise eligible, the begin date of his vendor eligibility is August 20, even though he was admitted to the nursing facility on August 12 and was found to need no specialized services. When the Eligibility Specialist receives notification that the I124 information is available and they have received the DA-625, they must enter information on the Facility and Placement Information Details (FACPLACE or FMJ4) screen and complete an eligibility determination (EDRES). WIBCAs for vendor may be necessary if approved for spend down or non-spend down prior to vendor approval. The effective date of the surplus is September 1, because Mr. V. was not in the facility on the first day of August.