M1001D Determining Eligibility For Inpatient Hospital Care (IHC) Benefits

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Purpose: This section will assist in determining whether individuals are eligible for Inpatient Hospital Care (IHC) benefits.

Current Policy Effective Date: September 1, 2010

Date Last Reviewed: June 24, 2010

Previous Policy: October 1, 2009

POL M1001D: DETERMINING ELIGIBILITY FOR INPATIENT HOSPITAL CARE (IHC) BENEFITS

1. Applicants Must Meet Basic Eligibility Factors

Refer to Section M600 for a description of all basic eligibility factors.

2. 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.

3. 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.

4. 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.

5. 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 Medicaid Table 8 to determine if assets are countable.

6. 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.

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.

7. Benefits Begin First of Month After Meeting 30-Day Requirement

Once applicants meet the 30-day requirement, benefits must be authorized back to the first day of the month in which the institutionalization began, if eligible.

8. Clients Pay Patient Contribution

Client is required to pay a contribution toward the cost of care.

Refer to Section M906 for details on calculating the patient contribution.

9. Clients May Pay Prorated Amount

If the client does not reside in a hospital 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.

10. Clients May Not Pay Patient Contribution First Month

Inpatient Hospital 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 residence.

11. 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.

12. Clients May Lose Benefits

The case will close on the first day of the next month when any of the following occur:

· Client leaves hospital.

· Client enters a public institution, excluding Uinta Hall.

· Client dies.

· Client does not complete review.

· Client determined no longer eligible.

Reference:

Defining Group: 42 CFR 435 Subpart F

42 CFR 435.236

Income: 42 CFR 435 Subpart K

Resources: 42 CFR 435 Subpart L

Clarifying Information:

1. Resource Transfer Provisions Do Not Apply.

Training Link: Not available at this time.

Worker Responsibilities:

Countable Income

1. Refer to Section M901 for information on countable income.

Determining Countable Resources

1. Refer to Section M801 for information on countable resources.

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. Send email to the Eligibility Unit with the name and case number of the applicant.

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. Enter subtype “H3” on MERE screen in EPICS for all months, including the retroactive period.

3. Authorize case on SSRM screen in EPICS, using appropriate code from Medicaid Table 3.

4. Send approval notice from Medicaid Table 16.

Denying Benefits

1. Enter program type “ME SS” on SEPA screen in EPICS.

2. Enter subtype “H3” on MERE screen in EPICS.

3. Deny case on SSRM screen in EPICS, using appropriate code from Medicaid Table 15.

4. Send denial notice from Medicaid Table 16.

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 10-Day closure notice from Medicaid Table 16 when an adverse action has occurred.

EqualityCare Eligibility Manual