0815.070.00 Claimant Leaves the Vendor Facility

When a claimant (receiving vendor based on OAA, PTD, or AB criteria) leaves a vendor facility for a non-vendor living arrangements, the action taken will depend on the new living arrangements and whether or not the claimant has a spouse. The eligibility specialist must establish the new living arrangement.

When a single individual leaves a vendor facility the individual will remain eligible for Medicaid either on a non-spend down or spend down basis. A married claimant may be ineligible based on assets of the spouse, unless:

For a married claimant (not receiving HCB waiver services) whose spouse is not on Medicaid, complete a reinvestigation to determine if the claimant remains eligible based on the couples' assets. Continue the claimant's eligibility as MA non-spend down until the reinvestigation is complete. If the claimant remains eligible on available resources, follow the steps below based on the living arrangement.

NOTE: If the claimant leaves the vendor facility and goes to a hospital (other than an institution in which Medicaid may not be continued), record the information and take no further action for 30 days. If, after 30 days, the claimant remains in the hospital, determine if the claimant would continue to be eligible for MA non-spend down or spend down basis.

0815.070.05 Vendor Facility to SNC Facility

If the claimant leaves the vendor facility and goes to a Residential Care Facility, Assisted Living Facility (formerly RCF II), or a non-vendor Nursing Facility, have the claimant or their representative sign an application for SNC. For single individuals and married claimants with a spouse receiving Medicaid take the following steps:

  1. Send an IM-80 (Advance Notice of Adverse Action) advising the claimant that s/he is no longer eligible for vendor payments effective with the date s/he left the vendor facility. S/he continues to be eligible for all other Medicaid services.
  2. Follow the procedures in Section 0600.000.00 to determine the amount of the claimant's SNC grant. It is not necessary to re-verify income or assets prior to approving for SNC, if a reinvestigation has been conducted on the MA vendor case within the preceding 6 months. A priority should be set to conduct a SNC reinvestigation 12 months after the last MA reinvestigation.
  3. If the SNC case cannot immediately be approved, change the MA case to non-spend down while the SNC is pending. This is necessary because claimants with a vendor level of care cannot receive some Medicaid services from a provider other than the vendor facility in which they reside.
  4. Once the SNC application is ready to approve, enter IMU5 transactions to close the MA case and approve the SNC on the same day.
  5. Send the claimant a SNC approval letter along with a notice that vendor payments have been discontinued.

For a married claimant whose spouse is not on Medicaid follow the same steps, except that a reinvestigation must always be completed to determine if the claimant remains eligible based on the couples' assets. If ineligible based on the spouse's resources or failure to cooperate with the reinvestigation take the following actions:

0815.070.10 Vendor Facility to Private Home, not receiving HCB

If the claimant leaves the vendor facility and goes to his/her own home or a relative's home and is NOT receiving HCB waiver services, take the following steps:

  1. For a married claimant whose spouse is not on Medicaid, complete a reinvestigation to determine if the claimant remains eligible based on the couples' assets. Continue the claimant's eligibility as MA non-spend down until the reinvestigation is complete. A reinvestigation is not required for single individuals and married claimants with a spouse on Medicaid.
  2. If a decision on the claimant's eligibility non-spend down/spend down MA cannot immediately be made, change the MA case to non-spend down while the decision is pending. This is necessary because claimants with a vendor level of care cannot receive some Medicaid services from a provider other than the vendor facility in which they reside.
  3. If ineligible based on the spouse's resources or failure to cooperate with the reinvestigation, send an Advance Notice of Adverse Action (IM-80) advising the claimant that s/he is no longer eligible for Medicaid effective the day after the IM-80 expires s/he is no longer in a vendor facility and the reason ineligible for non-spend down/spend down coverage. Close the case when the IM-80 expires and send the claimant a notice of the closing (IM-33).
  4. If eligible on available resources, determine if the claimant will be non-spend down or spend down.
  5. Send an Advance Notice of Adverse Action (IM-80) advising the claimant that s/he is no longer eligible for vendor payments effective with the date s/he left the vendor facility. S/he continues to be eligible for all other Medicaid services, if eligible as a non-spend down. If determined to be spend down, include the spend down amount, the effective date, and his/her options for meeting spend down (See Section 0810.010.00). A claimant going to spend down continues to be eligible for all other Medicaid services as a non-spend down until the effective date of the change to spend down.
  6. At the end of the advance notice period for cases going to non-spend down, update IMU5 to the non-spend down level of care and reason (if it has not already been done). Send the claimant a notice that vendor payments have been discontinued and the s/he remains eligible for all other Medicaid services as a non-spend down.
  7. At the end of the advance notice period for cases going to spend down, first update IMU5 to the non-spend down level of care and reason (if it has not already been done). Next update IMU5 to the spend down level of care and reason following the procedures for changing a case from non-spend down to spend down (refer to Section 0840.010.10). Send the claimant a notice that vendor payments have been discontinued and s/he remains eligible for all other Medicaid services as a non-spend down until the first month the case becomes a spend down.

0815.070.15 Vendor Facility to Private Home, receiving HCB

If the claimant leaves the vendor facility and goes to his/her own home or a relative's home and is receiving Home and Community Based (HCB) waiver services under the Elderly and Disabled waiver, take the following steps:

  1. Verify that DHSS Division of Senior and Disability Services has authorized the HCB waiver services.
  2. Complete a budget to determine if the claimant's income is below the special income limit for the HCB waiver.
  3. If authorized for the HCB waiver services and under the income limit, send an Advance Notice of Adverse Action (IM-80) advising the claimant that s/he is no longer eligible for vendor payments effective with the date s/he left the vendor facility. S/he continues to be eligible for all other Medicaid services.
  4. At the end of the advance notice period, update IMU5 to the HCB level of care and reason. Send the claimant a notice that vendor payments have been discontinued and that s/he remains eligible for all other Medicaid services as a non-spend down.

If not authorized for the HCB waiver services or over the income limit, follow the procedures in Section 0815.070.10 Vendor Facility to Private Home, not receiving HCB.