0815.000.00 Vendor Eligibility

0815.035.15 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 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), and the applicant or participant is found to be MR, MI or DD, 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
  • The first day of the third month prior to application (prior quarter determination) (see 0815.045.00 Prior Quarter Vendor), or
  • The date DMH completed the Level II screening

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. V. was admitted to the nursing facility on August 12. He applied for vendor benefits on the same date.  The DA-124C indicated the need for a level II screening. COMRU received the forms on August 16 and entered the information on the DA-124 screen on August 17. COMRU certified Mr. V. or NF level of care. The level II screening was completed by DMH on August 20. The eligibility specialist received the DA-625 on August 23, showing that Mr. V. was MI, but that his needs could be met at the nursing facility in which he was residing. Because the applicant was found to be MI, the begin date of vendor eligibility cannot be before the level II screening was completed by DMH. If Mr. V. was otherwise eligible, the begin date of his vendor eligibility is August 20, even though he was admitted to the nursing facility on August 12 and was found to need no specialized services. When the Eligibility Specialist receives notification that the I124 information is available and they have received the DA-625, they must enter information on the Facility and Placement Information Details (FACPLACE or FMJ4) screen and complete an eligibility determination (EDRES).  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 September 1, because Mr. V. was not in the facility on the first day of August.

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.