MO HealthNet for the Aged, Blind, and Disabled (MHABD) Manual

0815.000.10 Definitions for Vendor Coverage

IM-120 November 18, 2021; IM-59 June 25, 2015; IM-33, March 29, 2012; IM-31 June 21, 2011; IM-38 June 11, 2009; IM-102 December 03, 2008

The following alphabetical list includes definitions and explanations of some of the terms used in the Vendor program.

Allotment: a portion of an institutionalized individual’s income which is made available to a community spouse, minor children or dependent relatives. The amount of this allotment is deducted from the individual’s income when calculating the surplus. The allotment is determined by eligibility staff.

Community Spouse: the spouse of an institutionalized participant with whom the participant was living prior to the institutionalization. This includes cases where there is involuntary separation because one member of the couple is out of the home to receive medical or nursing home care.

COMRU: the Central Office Medical Review Unit. A section of the Department of Health and Senior Services, Division of Senior and Disability Services, COMRU determines whether the vendor participant needs the level of care provided by the nursing facility, psychiatric hospital, or institution for the intellectually disabled in which s/he resides.

Dependent Child: a child of either the institutionalized spouse or the community spouse, who lives with the community spouse and can be claimed as a dependent for income tax purposes under the IRS Code.

Dependent Parent: a parent of either the institutionalized spouse or the community spouse, who lives with the community spouse and can be claimed as a dependent for income tax purposes under the IRS Code.

Dependent Sibling: a sibling of either the institutionalized spouse or the community spouse, who lives with the community spouse and can be claimed as a dependent for income tax purposes under the IRS Code.

Excess Shelter Expense: when determining the allotment to the community spouse, the dollar amount by which the community spouse’s shelter expenses exceed the shelter expense standard.

Initial Assessment: a process for determining if a potential resident is medically certified for NF, ICF/IID, or MHC level of care. The attending physician or facility completes form DA-124A/B and sends it to COMRU, where the State Medical Consultant makes the determination.

Institutionalized Participant: an individual who enters a psychiatric hospital, institution for the intellectually disabled, or a MO HealthNet certified bed in a nursing facility and is expected to remain for at least 30 days.

Institutionalized Spouse: an institutionalized participant who has a community spouse with whom the participant was living prior to the institutionalization. This includes cases where there is involuntary separation because one member of the couple is out of the home to receive medical or nursing home care.

Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID): Individuals who qualify for an ICF/IID level of care reside in a state institution for the intellectually disabled, and have been determined by COMRU to need the care provided by that facility.

JCAHO Facility: a psychiatric health facility accredited by the Joint Commission on the Accreditation of Healthcare Organizations. These facilities may provide inpatient psychiatric treatment to individuals under age 21.

Level of Care: for vendor purposes, a designation of the type of care the institutionalized participant needs. The Level of Care determination is made by COMRU and communicated to FSD via the I124 screen (DA-124 Inquiry Report). Levels of Care which qualify for vendor are:

NF: nursing facility. Individuals who qualify for NF level of care reside in a MO HealthNet certified bed in a nursing facility, and have been determined by COMRU to need skilled or intermediate level nursing care.

MHC: psychiatric hospital. Individuals who qualify for MHC level of care reside in a state psychiatric hospital or JCAHO facility, and have been determined to need the care provided by that facility.

Maximum Monthly Maintenance Standard: the highest dollar amount that can be allowed for the support of the community spouse when determining the community spouse allotment. This figure is determined by federal policy. The amount is updated annually, and the information is posted online. The maximum monthly maintenance standard is listed in APPENDIX B.

Medicaid (MO HealthNet) Certified Bed: A bed designated by a nursing facility to accommodate a resident for whom MO HealthNet vendor payments are made.

Medicare Certified Bed: A bed designated by a nursing facility to accommodate a resident for whom Medicare payments are made.

Minimum Monthly Maintenance Standard: the lowest dollar amount that will be allowed for the support of the community spouse or dependent when determining their allotment(s). This figure is determined by federal policy. The Minimum Monthly Maintenance Standard is listed in APPENDIX B.

Minimum Monthly Maintenance Needs Allowance (MMMNA): Name in Section 1924 of the Social Security Act for the Total Monthly Maintenance Standard.

Minor Child: a child under the age of 21.

Preadmission Screening: a process for determining the admissibility of a potential resident of a nursing facility. The screening is intended to determine whether the potential resident is intellectually disabled or developmentally disabled.

Shelter Expense Standard: a dollar figure which represents the amount included in the minimum maintenance standard for shelter expenses. This figure is determined by federal policy, and is used in calculating the allotment to the community spouse. (See Excess Shelter Expense and Total Monthly Maintenance Standard.) The Shelter Expense Standard is listed in APPENDIX B.

Surplus Amount: a dollar amount which represents the portion of the institutionalized participant’s income which is available to pay the nursing home cost. The portion paid by MO HealthNet will be the facility cost minus the surplus amount. The surplus amount is determined by eligibility staff.

Telephone Standard: a dollar figure which represents the cost of basic telephone service. When completing an allotment determination, this figure may be used for calculating a community spouse’s total shelter expenses. This figure is determined by federal policy. The amount is updated annually, and the information is posted online. The telephone standard is listed in APPENDIX B.

Total Monthly Maintenance Standard: in determining the community spouse’s allotment, this figure is determined by adding the minimum maintenance standard and the excess shelter expense.

Utility Standard: a dollar figure which represents the cost of household utilities. When completing an allotment determination, this figure may be used for calculating a community spouse’s total shelter expenses. This figure is determined by federal policy. The amount is updated annually, and the information is posted online. ┬áThe utility standard is listed in APPENDIX B.