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POL 1001E: DETERMINING ELIGIBILITY AND COST OF CARE FOR ICF-MR (Wyoming Life Resource Center)
1. Applicants Must Meet Basic Eligibility Factors
Reference Section M600 for a description of all basic eligibility factors.
2. Applicants Must Meet Level of Care Requirement
Applicants must be approved for ICF/MR level of care indicated on the LT-MR-104.
3. Applicants Must Meet Disability Requirements
Applicants meeting the level of care requirement per the LT-MR-104 fulfill disability requirements.
4. SSI Eligibles Do Not Need to Submit Application
If SSI is lost, an application will be required to redetermine eligibility.
5. 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, they must do the following:
· Clients must pay privately for room and board expenses.
· Medical assistance is not terminated.
6. Applicants Must Meet Income Requirements
Require the countable income to be within the maximum income standard per month. Reference Medicaid Table 1A to see income standards. Reference Section M901 to determine if income is countable.
7. Applicants Must Meet Resource Requirements
Require the countable resources to be within the maximum resource limit. Reference Medicaid Table 7 to see resource standards. Reference Section M801 to determine if resources are countable.
8. Some Services Withheld for Nonexempt Resource Transfers
Nonexempt 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 nonexempt resources for less than fair market value, but meet all other eligibility factors, a penalty period must be imposed. During the penalty period:
· Payment for Wyoming Life Resource Center services must be withheld.
· Other Medicaid services must be authorized.
Clients must receive notification that they are Medicaid eligible even though room and board will not be covered for the penalty period.
Reference Section M803 to determine if a resource transfer is exempt.
9. Benefits Begin First Day of Month of Institutionalization
Applicants are not required to meet the 30-day stay.
10. 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 from an uncompensated resource transfer.
Reference Section M906 for details on calculating the patient contribution.
11. Clients May Pay Prorated Amount
If the client does not reside in the facility for a full month, they may pay a prorated amount based on the number of days they resided in the facility. Reference Section M906 for details on calculating the patient contribution.
12. Clients May Not Pay Patient Contribution First Month
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 placement.
13. Clients in Wyoming Life Resource Center May Continue Receiving Hospice
If Hospice-eligible clients enter the Wyoming Life Resource Center 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.
14. Clients May Enter Wyoming Life Resource Center from Other Facilities
Clients entering Wyoming Life Resource Center must obtain a new LT-MR-104.
15. Clients Must Be Reviewed
Clients must be periodically reviewed every 12 months to determine continued eligibility. Reference 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.
16. Clients May Lose Benefits
The case will close on the first day of the next month when any of the following occur:
· Client leaves Wyoming Life Resource Center.
· Client does not complete review.
· Client enters a public institution, excluding Uinta Hall.
· Client dies.
· Client determined no longer eligible.
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