0815.000.00 Vendor Eligibility

0815.070.05 Vendor Facility to SNC Facility

If the claimant leaves the vendor facility and goes to a Residential Care Facility, Assisted Living Facility (formerly RCF II), or a non-vendor Nursing Facility, have the claimant or their representative sign an application for SNC. For single individuals and married claimants with a spouse receiving Medicaid take the following steps:

  1. Send an IM-80 (Advance Notice of Adverse Action) advising the claimant that s/he is no longer eligible for vendor payments effective with the date s/he left the vendor facility. S/he continues to be eligible for all other Medicaid services.
  2. Follow the procedures in 0600.000.00 Supplemental Nursing Care (SNC) to determine the amount of the claimant’s SNC grant. It is not necessary to re-verify income or assets prior to approving for SNC, if a reinvestigation has been conducted on the MA vendor case within the preceding 6 months. A priority should be set to conduct a SNC reinvestigation 12 months after the last MA reinvestigation.
  3. If the SNC case cannot immediately be approved, change the MA case to non-spend down while the SNC is pending. This is necessary because claimants with a vendor level of care cannot receive some Medicaid services from a provider other than the vendor facility in which they reside.
  4. Once the SNC application is ready to approve, enter IMU5 transactions to close the MA case and approve the SNC on the same day.
  5. Send the claimant a SNC approval letter along with a notice that vendor payments have been discontinued.

For a married claimant whose spouse is not on Medicaid follow the same steps, except that a reinvestigation must always be completed to determine if the claimant remains eligible based on the couples’ assets. If ineligible based on the spouse’s resources or failure to cooperate with the reinvestigation take the following actions:

  • Reject the SNC application and send the claimant a notice with the rejection reason.
  • Send an IM-80 (Advance Notice of Adverse Action) advising the claimant that s/he is no longer eligible for Medicaid effective the day after the IM-80 expires as s/he is no longer in a vendor facility and the reason s/he is ineligible for non-spend down/spend down coverage.