MEMORANDUM

DISCUSSION:

The purpose of this memorandum is to clarify policy regarding the eligibility start date when an active MO HealthNet participant is admitted to a vendor facility. A current MHABD participant entering a vendor facility is a change in circumstances and does not require a new application for vendor coverage.

When Does Eligibility Begin

The eligibility begin date for vendor long term care coverage is based on:

• The date the individual enters the vendor facility,
• The eligibility date on the Initial Assessment-Social and Medical form DA-124, and
• When the change in circumstances is reported.

 
An individual receiving MO HealthNet for Aged, Blind, and Disabled (MHABD), who enters a vendor facility, is required to report this change in circumstance. Nursing home facilities or others, such as family or friends, may report when a MHABD participant has been admitted to a nursing facility. 

The individual is eligible for vendor benefits the date they enter the facility when:

• The change is reported within 10 days (timely),
• The DA-124 supports eligibility from the date of admission.

If the change is reported more than 10 days from the date of the change (untimely), the individual is eligible for vendor benefits the first day of the month in which the change is reported, as long as the DA-124 supports eligibility for the first day of the of the month the change is reported.

EXAMPLE #1:  Mr. A has an active MHABD non spend down case.  He enters a vendor facility on August 10.  His authorized representative reports this move on Aug 20.  His DA-124 is received September 15th, with date of assessment and eligibility Aug 20.   The eligibility specialist (ES) determines he is otherwise eligible for vendor coverage.  Because Mr. A entered the facility after the first of the month he will have no surplus in August.  If he is responsible for a surplus, it will begin effective September.  When the ES completes the eligibility determination (EDRES), FAMIS will authorize vendor beginning September 1.  The ES will complete two (2) Worker Initiated Budget Calculations (WIBCA) for August.  The first will cover Aug 1 through Aug 19 for MHABD non spend down, the second will cover Aug 20 through Aug 31 for vendor. 

EXAMPLE #2:  Ms. B has an active MHABD non spend down case.  She enters a vendor facility on August 10.  Her authorized representative reports the change on September 20.  The DA-124 is received by the FSD on September 30, with date of assessment and eligibility of August 10.  The eligibility specialist (ES) determines she is otherwise eligible for vendor coverage.   Ms. B is eligible for vendor coverage effective September 1, the first day of the month the change was reported.  No WIBCA will be entered to give vendor coverage for prior months.  If she is responsible for a surplus, it will be effective September 1, since she was in the facility on the first day of the month.

EXAMPLE #3:  Mr. C has an active MHABD non spend down case.  He enters a vendor facility on August 27.  His brother reported his change in residence on Sept 2, timely report.  The DA-124 is received by FSD on Sept 30, with date of assessment and eligibility of August 27.   The eligibility specialist (ES) determines he is otherwise eligible for vendor coverage.  Mr. C is eligible from the date he entered the facility, his move was reported timely and the DA-124 supported his eligibility on that date.

NOTE:  In all examples, the individual was active on MHABD and the move to a vendor facility is a change which does not require an application.

When the Change Is Not Reported by the Participant

If the admission is reported by the nursing facility, the facility representative should submit the Facility Notification Information Sheet (FNIS) or contact the Family Support Division (FSD) directly within 10 days of the resident's admission. The timely report of the admission allows the entire period of institutionalization to be covered if the participant is determined eligible for vendor from the date of admission. The FNIS and contact information for the Vendor Units are available at the DSS Website at https://dss.mo.gov/fsd/ncare.htm.

Due to confidentiality rules (see 0130.000.00 Legal Aspects), FSD staff may not be able to share case information with the person reporting the change, unless the reporter is an authorized representative, attorney-in-fact, or the conservator/guardian for the participant, and the FSD has documentation of this. The Nursing Facility Authorization Form (IM-6 NF) or an Authorization for Disclosure of Consumer Medical/Health Information form (650-2616 (HIPAA)) can be used to give the FSD permission to discuss case details with a person who is not an authorized representative for  the participant.

Income Maintenance Manual section 0815.015.00 has been updated to clarify the begin date for vendor assistance when an active MO HealthNet participant reports a change in living arrangements.

NECESSARY ACTION:

• Review this memorandum with appropriate staff.

JG/vb/ad