0815.050.00 Claimant Not in Vendor Facility on the First Day of the Month of Application

If the participant was not in the nursing home or institution on the first day of the month of application, determine eligibility for MO HealthNet for the Aged, Blind, and Disabled spend down/non-spend down between the first day of the month of application and the date the participant entered the nursing home.

EXAMPLE: Mr. B. enters the hospital on 2/6. It is determined on 2/23 that he needs to be placed in a nursing facility. He signs the MHABD application on that date. On 3/11, he enters the nursing home. The attending physician completes the DA-124A/B and DA-124C on that date. On 3/15, COMRU completes the medical certification indicating that Mr. B. is eligible for NF level of care. No Level II screening is required. On 3/26, the eligibility specialist determines that Mr. B. was eligible on all December 1973 eligibility factors as of 3/11.

• Mr. B. is eligible for vendor coverage as of 3/11, the date he entered the nursing facility.
• Because the NF eligibility as of 3/11 does not cover Mr. B.'s hospital bills for 2/6 through 3/10, FAMIS determines his eligibility for MO HealthNet for the Aged, Blind, and Disabled spend down/non-spend down from 2/1 (the first day of the month of application) through 3/10, using the December 1973 eligibility requirements (spend down or non-spend down). Mr. B is determined to be eligible for MHABD spend down for 2/1 through 3/10. The Medicaid Category History (FM4L or MEDHIST) screen shows MHABD spend down coverage for 2/1/-3/10 and vendor coverage beginning 3/11.

0815.050.05 Applicant or Participant Not in Vendor Facility in the Prior Quarter Has Medical Expenses in the Prior Quarter

If the applicant or participant had medical expenses in the three months prior to application, determine eligibility for MHABD during the prior quarter.

EXAMPLE: Mr. B. (from the previous situation) had medical bills in November, December and January, prior to entering the hospital on 2/6. On the Application Detail (FM17) screen in FAMIS enter a "Y" in response to the question, "Do you want us to explore Prior Quarter Eligibility? ".  Based on the data entered, FAMIS will explore eligibility for the prior quarter for Mr. B under MHABD spend down/non-spend down guidelines since he was not in the facility during this time period.

NOTE: Always review the Budget Summary screen prior to authorizing a case action in FAMIS. From the MHABD Action Authorization (FMD9) screen, 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 to ensure all countable income is included in the budget. If the income is incorrect, return to the appropriate Income (FMX0) screen and Income Amount (FMX3) screens and make any necessary correction to inaccurate information.