0815.075.00 Claimant Moves from One Type of Vendor Facility to Another

If a claimant moves from one type of vendor facility to another, the action taken will depend on the type of facility.

Determine if the claimant is medically certified for the appropriate level of care for the type of facility entered. (See Section 0815.025.00.)

0815.075.05 Claimant Moves to a Nursing Facility from Another Type of Vendor Facility

If entering a nursing facility, determine that the preadmission screening has been completed. (See Section 0815.030.00.)

1. If the claimant is medically certified, make the appropriate change in IMU5.
2. If the claimant is not medically certified:
   • 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.
   • Follow procedures in Section 0815.070.10 Vendor Facility to Private Home, not receiving HCB to determine eligibility for Medical Assistance spenddown/non-spenddown coverage.

0815.075.10 Nursing Facility or Institution for the Intellectually Disabled to Mental Hospital

If the participant leaves a nursing facility or institution for the intellectually disabled and goes to a state psychiatric hospital, the procedure will depend on the participant's age.

0815.075.10.05 Claimant Age 22 to 65 Goes from NF or IMR to State Mental Hospital

If a participant age 22 to 65 leaves the vendor facility and enters the State Hospital (General Medical and Surgical or Psychiatric Sections):

1. Record the information at the Eligibility Unit Member Role/EUMEMROL/FM3Z screen in FAMIS.
2. Contact the resource investigator at the facility to establish:
   1. anticipated length of stay and/or possible date of release
   2. plans for placement and/or living arrangements upon release
3. If plans have been made for the participant's release:
   1. set a priority to follow up on the participant's planned date of release
   2. take necessary action, based on the participant's living arrangements at the time of release from the State Hospital.
4. If no plans have been made for the claimant's release, set a priority to follow up in 21 days.
   1. If participant is still residing in the facility and no plans have been made for his/her release, change the claimant's level of care to T (Title XIX only).
   2. Send the participant , legal guardian or relative, and the nursing facility, the notification letter of action taken (IM-33). Advise the claimant that s/he is ineligible for vendor payments.
   3. Complete an MA determination as if the participant were in his/her own home.

0815.075.10.10 Participant Age 65 or Older Goes from NF or IMR to State Mental Hospital

If a participant who is 65 year of age or older leaves the vendor situation and enters the State Hospital:

1. Record the information at the Eligibility Unit Member Role/EUMEMROL/FM3Z screen in FAMIS.
2. Contact the resource investigator at the facility to establish:
   1. whether the participant has been admitted to the General Medical and Surgical Unit or the Psychiatric Unit of this hospital.
   2. anticipated length of stay and/or possible date of release
   3. plans for placement and/or living arrangements upon release.
3. If plans have been made for the participant's release:
   1. set a priority to follow up on the participant's planned date of release
   2. take necessary action, based on the participant's living arrangements at the time of release from the State Hospital.
4. If no plans have been made for the participant's release, set a priority to follow up in 21 days.
   1. If, after 21 days, no plans have been made for the participant's release and s/he is residing in the General Medical and Surgical Section of the State Hospital:
   2. record the information at the Eligibility Unit Member Role/EUMEMROL/FM3Z screen in FAMIS.
   3. Complete an MA spenddown/non-spenddown determination as if the claimant were in his/her own home.
5. If, after 21 days, no plans have been made for the participant's release and s/he is residing in the Psychiatric Section of the State Hospital, determine claimant's eligibility for MHC level of care by obtaining the medical certification on the DA-124. (See Section 0815.030.00.)

If a participant, 65 years of age or older, leaves the NF or IMR for the State Mental Hospital and is certified by COMRU for MHC Level of Care:

1. Record the change in the case record
2. Enter the new level of care in the system
3. Send the participant, legal guardian, relative and new facility a notification letter (IM-62).

If the participant who is 65 years of age or older is not medically certified by COMRU for MHC level of care but continues to meet all other Medical Assistance eligibility:

1. Record information at the Eligibility Unit Member Role/EUMEMROL/FM3Z screen in FAMIS.
2. Complete a MA spenddown/non-spenddown determination as if the participant were in his/her own home.

0815.075.15 Nursing Facility or Mental Hospital to Institution for the Intellectually Disabled

If entering an Institution for the Intellectually Disabled (IMR), determine if the participant is medically certified for the IMR level of care (See Section 0815.030.00.)

• If the claimant is medically certified, make the appropriate change in IMU5.
• If the claimant is not medically certified:
  1. Send an IM-80 (Advance Notice of Adverse Action) advising the participant that s/he is no longer eligible for vendor payments effective with the date s/he left the previous vendor facility.
  2. Follow procedures in Section 0815.070.10 Vendor Facility to Private Home, not receiving HCB to determine eligibility for Medical Assistance spenddown/non-spenddown coverage.