If an applicant had medical expenses while in the vendor facility in the three months prior to the month of application, s/he may be eligible to have MO HealthNet vendor benefits as of the first day of the third month prior to the month of application. This is PQ coverage.
Explore eligibility for and explain the availability of PQ coverage to each vendor applicant.
The eligibility determination for PQ coverage is separate from the eligibility determination of current vendor coverage. An applicant does not have to be currently eligible for vendor coverage to be approved for PQ vendor coverage.
The effective date of PQ coverage can be no earlier than the first day of the third month prior to the month of application, and may extend up to but not including the first day of the month of application. When the applicant has unpaid medical expenses in the PQ and is determined to be ineligible for MO HealthNet during the PQ, staff should record an explanation of the eligibility begin date in the eligibility system. Individuals may apply or reapply for PQ for up to one year after the application. They may apply for PQ in person, by telephone, or in writing.
To determine the applicant’s MO HealthNet eligibility for the PQ, use:
- MHABD criteria for any portion of the PQ that the applicant was not in the vendor facility (See Section 0815.050.05), or.
- MHABD Vendor criteria (December 1973 eligibility requirements, medical certification of level of care, preadmission screening if applicable, and surplus computation) for any portion of the PQ that the applicant was in the vendor facility.
EXAMPLE: Ms. X. enters a MO HealthNet certified bed in a nursing facility on February 12. Ms. X. applies for MHABD vendor on July 6, when her son comes to town to assist her with her affairs. On July 9, COMRU certifies Ms. X for NF level of care effective February 12. The DA-124C shows that no Level II screening is required. Ms. X. met December 1973 eligibility factors as of February 12. She is eligible for PQ vendor coverage as of April 1, the first day of the third month prior to the month of application.
NOTE: WIBCAs for vendor may be necessary if approved for MHABD Spend Down/Non-Spend Down prior to vendor approval.