0815.000.00 Vendor Eligibility

0815.035.05 Effective Date of Vendor Coverage for Applicant or Participant in a Nursing Facility When No Level II Screening Is Required

IM-33 March 29, 2012; IM-117 October 24, 1997

If a Level II screening is not required (see 0815.025.05 Preadmission Screening Process), vendor eligibility begins with the latest of the following dates:

  • The date the applicant or participant is eligible on all factors
  • The date the applicant or participant entered the nursing facility, or
  • The first day of the third month prior to the month of application (prior quarter determination) (see 0815.045.00 Prior Quarter Vendor)

Note: The applicant may be eligible for MHABD spend down or non-spend down from the first day of the prior quarter (third month prior to the month of application) to the date s/he entered the nursing facility. See 0815.050.00 Claimant Not in Vendor Facility on the First Day of the Month of Application.

EXAMPLE: Ms. W. was admitted to a nursing facility on March 18. She applied for vendor benefits on March 21. COMRU certified Ms. W. for NF (nursing facility) level of care. No Level II screening was required, because Ms. W. was not suspected of MR, MI or DD. The eligibility specialist completed the eligibility determination on April 21. Ms. W. was found to be eligible on all factors as of the date of admission. The eligibility specialist enters the level of care determination on the Facility and Placement Information Details (FACPLACE or FMJ4) screen in FAMIS, completes an eligibility determination (EDRES) and authorizes the actions to approve the spend down/non-spend down and vendor benefits. If Ms. W requested prior quarter coverage and is eligible on all factors during the prior quarter months, she should be approved for prior quarter spend down/non-spend down as of December 1.  She would have a partial month of coverage as spend down or non-spend down from March 1 – 17. The beginning date of vendor eligibility is March 18, the date she entered the nursing facility.  WIBCAs for vendor coverage may be necessary if she was approved for spend down or non-spend down prior to vendor approval.

The effective date of the surplus is April 1, because Ms. W. was not in the facility on the first day of March.

If all eligibility factors and verifications except the DA-124 A/B level of care are entered, the eligibility specialist should complete the eligibility determination (EDRES) for all other MHABD programs. If the eligibility specialist does not make the eligibility determination within 5 days, FAMIS will act to approve or reject the application based on the information entered.  Review the MO HealthNet Category History (MEDHIST) screen in FAMIS to confirm the dates of coverage and correct eligibility.