0815.000.00 Vendor Eligibility

0815.035.10 Effective Date of Vendor Coverage for Applicant or Participant in a Nursing Facility When Level II Screening Is Required and the Applicant or Participant Is Not Found to Be MR, MI or DD

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

If a Level II screening is required (See 0815.025.05 Preadmission Screening Process), but the applicant or participant is not found to be MR, MI or DD, the begin date for vendor is the same as above (0815.035.05 Effective Date of Vendor Coverage for Applicant or Participant in a Nursing Facility When No Level II Screening Is Required)

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: Mr. Z. was admitted to the nursing facility on June 5. He applied for MHABD on June 7. The DA-124C indicated the need for a Level II screening. COMRU certified Mr. Z. for NF level of care effective June 5. The Level II screening was completed by DMH showing that Mr. Z. was not MR, MI or DD. The eligibility specialist completed the eligibility determination on June 18.  Mr. Z. 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 Mr. Z is eligible on all factors during the prior quarter months, he may be approved for prior quarter spend down/non-spend down as of March 1.  He would have a partial month of coverage as spend down or non-spend down from June 1 – 4. The beginning date of vendor eligibility is June 5, the date he entered the nursing facility.  WIBCAs for vendor may be necessary if approved for spend down or non-spend down prior to vendor approval.  The effective date of the surplus is July 1, because Mr. Z was not in the facility on the first day of June.

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.