IM-#33, March 29, 2012

An applicant or participant between the ages of 21 and 65 in a state mental hospital does not qualify for vendor coverage on the basis of age.

EXCEPTION: Individuals who enter a Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) facility when they are under the age of 21 may continue to receive vendor services until they reach their 22nd birthday.

If the applicant or participant who does not qualify for vendor coverage on the basis of age has been in the mental hospital (psychiatric) for at least 21 days, s/he may be eligible for MHABD. Process the MHABD application as if the applicant or participant were in his/her own home. The eligibility specialist will also need to:

  1. Contact the resource investigator at the state mental facility to verify the applicant's or participant's inpatient status for the specific days in question and his/her anticipated length of stay.
  2. Establish, if possible, dates of commitment and/or release.
  3. If plans have been made for the applicant's or participant's release from the state hospital, verify the applicant's or participant's new address.
  4. If the applicant's or participant's financial need determination indicates a spend down:
    1. Verify the amount of incurred medical expenses for the applicant or participant by requesting a statement of covered expenses for the days in question.

      Note: The resource investigator will provide the eligibility specialist with a summary of allowable general medical/surgical expenses, based upon the countable number of days Room and Board Charges. These charges are revised annually.

    2. The verified per diem amount and the recorded number of eligible days (General Medical and Surgical) will be used when determining the applicant's or participant's spend down eligibility.
    3. If additional charges are required to meet spend down, request an itemized, daily breakout of all ancillary charges for the specific period of time.