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Purpose: This section will assist in determining whether an individual is eligible and the cost of care for Nursing Home/Swing Bed benefits.
Current Policy Effective Date: September 1, 2010
Date Last Reviewed: June 24, 2010
Previous Policy: October 1, 2009
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POL 1001A: DETERMINING ELIGIBILITY AND COST OF CARE FOR NURSING HOME/SWING BED
1. Applicants Must Meet Basic Eligibility Factors
Refer to Section M600 for a description of all basic eligibility factors.
2. Applicants Must Meet Medical Necessity Requirement
Verification of medical necessity must be obtained by accessing the Provider Web Portal through the LT101 tab located within ECOM.
Applicants meet the medical necessity requirement when the LT101 has any of the following:
· 13 or more points. Client may be served either in a nursing facility or swing bed OR on either HCBS-LTC or ALF waiver.
· DOES NOT have 13 points, but placement remains medically necessary to maintain optimal functioning and maintain the continued safety and welfare of the client.
· No approved LT101, due to death within three working days of admission to a nursing facility.
3. Applicants Must Be Aged, Blind Or Disabled
Applicants must meet one of the following factors:
· Aged – 65 or older.
· Blind – legally blind based on Social Security standards.
· Disabled – person who receives disability benefits from SSA or is determined disabled by WDH.
4. Applicants Must Meet 30-Day Requirement
Applicants must meet a 30-day requirement by any of the following:
· Remain in an institution for 30 consecutive days.
· Not completing the 30-day requirement due to death.
· Verified as SSI eligible.
5. SSI Eligibles Do Not Need To Submit Application
If client becomes ineligible for SSI, an application will be required to determine continued
eligibility under another coverage group.
6. Clients Meet Temporary Absence Criteria If Absent Up To 14 Days Annually
Clients meet the temporary absence requirement when they are absent up to 14 days in a year.
Medicaid will pay room and board for the 14-day period.
If clients exceed the 14-day temporary absence period:
· Clients must pay privately for room and board expenses.
· Medical assistance is not terminated.
7. Applicants Must Meet Income Requirements
Require the countable income to be within the maximum income standard per month. Refer to Medicaid Table 1A to see income standards. Refer to Section M901 to determine if income is countable.
8. Applicants Must Meet Resource Requirements
Require the countable resources to be within the maximum resource limit. Refer to Medicaid Table 7 to see resource standards. Refer to Section M801 to determine if income is countable.
9. Some Services Withheld For Resource Transfers
Resources cannot be transferred for less than fair market value during the look-back period, prior to application or when a client is receiving benefits.
If clients transfer resources for less than fair market value but meet all other eligibility factors, a penalty period must be imposed. The following will occur during the penalty period:
· Payment for nursing home facility services must be withheld.
· Other Medicaid services must be authorized.
· Clients must receive notification that they are Medicaid eligible even though nursing facility services will not be covered for the penalty period.
Refer to Section M803 to determine if an resource transfer is exempt and Section M804 for information on related penalties.
10. Benefits Begin First Month Of Eligibility
Once applicants meet the 30-day requirement of institutionalization, benefits must be authorized beginning with the first month of eligibility.
11. Applicants May Receive Retroactive Medicaid
Applicants may receive retroactive Medicaid benefits if they incurred medical bills during any of the
three months prior to application. Applicants are not eligible for room and board prior to the day an
LT101 is completed with met requirements.
Both approved and denied applicants must be reviewed. Reviewer must verify and determine eligibility
separately for each retroactive month to determine whether the case would have been eligible if an
application had been made. Medical bills may be paid for this period when eligible.
12. Clients Pay Patient Contribution
Client is required to pay a contribution toward the cost of care.
Require the client to pay toward the cost of care when a partial month penalty is imposed due to a transfer of a resource.
Refer to Section M906 for details on calculating the patient contribution.
13. Clients May Pay Prorated Amount
If the client does not reside in a nursing home for a full month or Medicare pays for the cost of care, prorate the patient contribution. Refer to Section M906 for details on calculating the patient contribution.
14. Clients May Not Pay Patient Contribution First Month
Nursing home clients, previously Medicaid eligible, do not pay a patient contribution during their first month of eligibility. Clients must pay a patient contribution the first full month following 30 days of nursing home residency.
15. Clients Pay No Patient Contribution In Month Of Transfer To HCBS
16. Clients In Nursing Home May Continue Receiving Hospice
If Hospice-eligible clients enter a nursing home after hospice eligibility begins, determine with Hospice if they are paying room and board as part of services.
Hospice benefits must continue to be authorized if clients continue to have a physician’s medical prognosis of six months or less to live. If clients do not have this medical prognosis any longer, determine eligibility for other Medicaid programs.
17. Clients May Enter Nursing Homes From Other Facilities
Clients entering nursing home must obtain a new LT101 if they have been in long term care or assisted living facilities for more than 60 days.
18. Clients Must Be Reviewed
Clients must be periodically reviewed every 12 months to determine continued eligibility. Refer to Section M1403 for information on reviewing eligibility.
A review is not required for SSI clients.
Clients must be reviewed for other Medicaid program eligibility before closing cases.
19. Clients May Lose Benefits
The case will close on the first day of the next month when any of the following occur:
· Client leaves nursing home.
· Client does not complete review.
· Client enters a public institution, excluding Uinta Hall.
· Client dies.
· Client determined no longer eligible.
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Reference:
Defining Group: 42CFR 435 Subpart F
42CFR 435.132
Income: 42CFR 435 Subpart K
Resources: 42CFR 435 Subpart L
Clarifying Information:
Training Link: Not available at this time.
Worker Responsibilities:
Indicating Eligibility For SSI Eligibles
1. Enter subtype “NM” on MERE screen in EPICS.
2. If client loses SSI, set individual as “OU” on SEPA screen in EPICS.
2A. Determine continued eligibility.
2B. Open new case.
Determining Countable Income
1. Refer to Section M901 for information on countable income.
Determining Countable Resources
1. Refer to Section M800 for information on determining countable resources.
Calculating Resource Transfer Penalty
1. Refer to Sections M803 and Section M804 for information on resource transfers and related penalties.
Accessing LT101 To Determine Medical Necessity
1. Log into the Provider Web Portal Through ECOM
1A. Click the LT101 tab from ECOM (the Provider Welcome page will open).
1C. Enter your User ID and Password on Provider Welcome page.
1Ci) Click on the “Log In” button (the ACS Wyoming Medicaid Home Page will open).
1D. Select the LT101 Inquiry link on the left hand side of the ACS Wyoming Medicaid Home Page (the LT101 Inquiry page will open).
1E. Conduct the client search by entering one of the following:
1Ei) EqualityCare ID or
1Eii) Combination of Name, Date of Birth and Gender or
1Eiii) Combination of Name and Social Security Number or
1Eiv) Combination of Date of Birth and Social Security Number.
1F. Click on the “Reset” button to reset your search criteria or the “Submit” button to submit the inquiry
(the LT101 Inquiry Results screen will open) or
1Fi) Message may appear that there are no LT101 records found (double check your inquiry information and resubmit your search if needed).
1G. Select the button corresponding to the Placement Summary you want to view.
1Gi) Click the “Submit” button(the Assessment of Medical Necessity for Long Term care web page will open).
1H. The Medical Necessity for Long Term Care web page contains the following information:
1Hi) Client Name, Address, Phone Number, DOB, SSN, Medicaid Number.
1Hii) Date of Referral, Date of Review.
1Hiii) Name of Facility, Admit date.
1Hiv) Expected to remain in medical institution for 30 consecutive days (shows yes or no).
1Hv) Placement summary.
1. Has 13 or more points. Client may be served either in a nursing facility or swing bed OR on either HCBS-LTC or ALF waiver.
2. DOES NOT have 13 points, but placement remains medically necessary to maintain optimal functioning and maintain the continued safety and welfare of the client.
3. DOES NOT have 13 points, and DOES NOT meet the medical necessity criteria for Long Term Care.
1Hvi) Score.
1Hvii) Case Manager/Care Coordinator or Project Out Transition Specialist.
1Hviii) Public Health Office, County Number.
1Hix) At the bottom of this page, you are given the options to either go “Back” to the Inquiry Results page, “Print”, Or conduct a “New Search”.
1Hx) Print this screen as verification of medical necessity for the case file.
Determining Disability For Applicants Not Receiving Social Security Disability
1. Provide applicant or client with the EC-300 EqualityCare (Medicaid) Disability Determination Application and instructions.
2. Direct the applicant or client to forward the completed packet and previous 12 months of medical records to WDH in the enclosed self addressed postage paid envelope at the following address:
EqualityCare/Medicaid
Attn: Eligibility Unit
6101 Yellowstone Road, Suite 210
Cheyenne, WY 82002
3. If applicant or client brings the EC-300 and medical records to the DFS Office:
2A. Mail, Fax or email a scanned copy of the EC-300 and medical records directly to the Eligibility Unit
2B. Do not keep a copy of the EC-300 or medical records.
4. Receive an approval or denial of the disability determination from WDH.
4A. WDH will provide a disability determination renewal date on all approvals.
4B. Require a new disability determination on a client who is not receiving benefits from SSA based on the above renewal date
provided by WDH.
Approving Benefits
1. Enter program type “ME SS” on SEPA screen in EPICS.
2. For 300% CAP, enter subtype “N3” on MERE screen in EPICS for all months, including the retroactive period.
3. For SSI Eligible, enter subtype “NM” on MERE screen in EPICS for all months, including the retroactive period.
4. For Combination SSI/SSA, enter subtype “NC” on MERE screen in EPICS for all months including, the retroactive period.
5. Authorize case on SSRM screen in EPICS, using appropriate code from Medicaid Table 3.
6. Send approval notice to the applicant from Medicaid Table 16 and Notice to Licensed Shelter Care Facility.
Denying Benefits
1. Enter program type “ME SS” on SEPA screen in EPICS.
2. For 300% CAP, enter subtype “N3” on MERE screen in EPICS.
3. For SSI Eligible, enter subtype “NM” on MERE screen in EPICS.
4. For Combination SSI/SSA, enter subtype “NC” on MERE screen in EPICS.
5. Deny case on SSRM screen in EPICS, using appropriate code from Medicaid Table 15.
6. Send denial notice to the applicant from Medicaid Table 16 and Notice to Licensed Shelter Care Facility.
Reviewing Cases
1. Refer to Section M1403 for information on reviewing cases.
Closing Cases
1. Close case on SSRM screen in EPICS for the appropriate benefit month, using appropriate code from Medicaid Table 15.
2. Send closure notice to the applicant from Medicaid Table 16 and Notice to Licensed Shelter Care Facility.
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