0815.000.00 Vendor Eligibility

If the claimant leaves the vendor facility and goes to his/her own home or a relative’s home and is NOT receiving HCB waiver services, take the following steps:

1. For a married claimant whose spouse is not on Medicaid, complete a reinvestigation to determine if the claimant remains eligible based on the couples’ assets. Continue the claimant’s eligibility as MA non-spend down until the reinvestigation is complete. A reinvestigation is not required for single individuals and married claimants with a spouse on Medicaid.
2. If a decision on the claimant’s eligibility non-spend down/spend down MA cannot immediately be made, change the MA case to non-spend down while the decision 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.
3. If ineligible based on the spouse’s resources or failure to cooperate with the reinvestigation, send an Advance Notice of Adverse Action (IM-80) advising the claimant that s/he is no longer eligible for Medicaid effective the day after the IM-80 expires s/he is no longer in a vendor facility and the reason ineligible for non-spend down/spend down coverage. Close the case when the IM-80 expires and send the claimant a notice of the closing (IM-33).
4. If eligible on available resources, determine if the claimant will be non-spend down or spend down.
5. Send an Advance Notice of Adverse Action (IM-80) 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, if eligible as a non-spend down. If determined to be spend down, include the spend down amount, the effective date, and his/her options for meeting spend down (see 0810.010.00 MO HealthNet Spend Down Coverage). A claimant going to spend down continues to be eligible for all other Medicaid services as a non-spend down until the effective date of the change to spend down.
6. At the end of the advance notice period for cases going to non-spend down, update IMU5 to the non-spend down level of care and reason (if it has not already been done). Send the claimant a notice that vendor payments have been discontinued and the s/he remains eligible for all other Medicaid services as a non-spend down.
7. At the end of the advance notice period for cases going to spend down, first update IMU5 to the non-spend down level of care and reason (if it has not already been done). Next update IMU5 to the spend down level of care and reason following the procedures for changing a case from non-spend down to spend down (refer to 0840.010.10 Non-Spend Down to Spend Down). Send the claimant a notice that vendor payments have been discontinued and s/he remains eligible for all other Medicaid services as a non-spend down until the first month the case becomes a spend down.