8173 Continuing Financial Eligibility - When circumstances change, adjustments will be made as follows:
8173.1 Medically Needy - If a person goes from independent living (including a non-Medicaid approved institution or specialized living arrangement) to long term care in a Medicaid approved institution or vice versa, the eligibility base will be changed as per 8131 depending on the age of the individual and applicability of spousal impoverishment. When an individual goes from independent living to long term care in a Medicaid approved institution, financial eligibility shall be recomputed for the actual time in independent living and a one month eligibility base established beginning either with the month of entrance in the case of a child or the month following the month of entrance for adults except as noted in 8113. However, if financial eligibility must be computed in accordance with 8172.2 (2)(b), the independent living base will be continued.
8173.2 Long Term Care to Independent Living - When an eligible individual goes from long term care in a Medicaid approved institution to independent living, a new six month eligibility base shall be established beginning with the month following the month the care arrangement ends for children and for institutionalized spouses for whom the spousal impoverishment income provisions of 8144 have been applied or the month the care arrangement ends for all others. In the latter situations, the amount of the previously established client obligation or the cost of care incurred by the individual in the month of discharge or service termination, whichever is less, shall be applied towards the spenddown for the new base. A new base would not, however, be required for an individual whose financial eligibility was being computed in accordance with 8172.2 (2)(b) and who goes from the adult care home to independent living. The six month base previously established in such cases would continue in these instances.
For all other changes in financial factors, the change will be incorporated into the appropriate eligibility base. Necessary case actions will be taken at the earliest possible time based on advance notice requirements.
8173.3 Long Term Care to HCBS - When an eligible individual goes from long term care in a Medicaid approved institution to an HCBS arrangement, the higher HCBS income standard shall be applied beginning with the month the HCBS arrangement begins and liability recomputed for that month. The resulting patient liability will be assigned entirely to the facility, even in instances where the total cost of care is less than the resulting liability. In these situations, KEES should not be updated with the HCBS information until the living arrangement changes (after the person physically leaves the facility). The new level of care and living arrangement are effective the date of discharge. HCBS Plans of Care may be backdated to ensure proper reimbursement to providers in these situations. Coordination between HCBS care coordinators and eligibility staff is necessary.
8173.4 HCBS to Long Term Care - When an eligible individual goes from an HCBS arrangement to long term care in a Medicaid approved institution, budgeting methodologies are dependent upon the anticipated duration of the stay.
For the first month, if the stay
is expected to exceed the month of entrance and the two following
months, the obligation established for the month of entrance shall
remain in effect but no liability is assigned to the NF and will be
applied to HCBS services provided in the month. LTC budgeting methodologies
begin the month following the month of entrance.
If the HCBS recipient enters a State Hospital, the effective date of
the new Level of Care and Living Arrangement codes is the day following
the day of entrance into the State Hospital. Current coding in place
authorizing HCBS as well as the previously established client obligation
should be left in place for the date of entrance.
If the HCBS recipient enters a Nursing Facility or Swing Bed Hospitals,
a TC (Temporary Care) Living Arrangement code should be entered with
an effective date of the day of NF entrance. The current Level of
Care code should be left in place. This combination of coding will
allow both the NF and the HCBS provider to receive reimbursement for
services provided on the day of entrance. The new Level of Care/Living
Arrangement codes authorizing only NF payment are effective the day
following the day of entrance into the NF.
If the total client obligation is not paid for HCBS care because the
cost of services was less than the obligation, because of this change,
no medical overpayment will be considered.
If the stay is not expected to exceed
the month of entrance and the two following months, HCBS budgeting
methodologies continue for the temporary period. Any HCBS obligation
would be applied to the HCBS services provided in either month and
no obligation applied to the cost of the institutional care. However,
because billing procedures differ for different institutional arrangements,
instructions for handling these situations also differ.
If the HCBS recipient enters
a State Hospital, no changes to LOTC are necessary, and the coding
established for HCBS payment is left in place for the duration
of the temporary period. If a child receiving services through
the SED waiver is approved for the special 14 day funding, HCBS
coding remains in place for the full 14 days. Changes in level
of care and living arrangement would be made effective for the
15th day.
If the HCBS recipient enters
a Nursing Facility or Swing Bed Hospital, the Living Arrangement
code is changed from HC to TC and left in place throughout the
duration of the temporary period. No other changes are necessary.
If the individual is hospitalized in general hospital prior to
entrance into the NF/Swing Bed, the HC code should be left in
place until the NF stay begins. However, the total anticipated
length of stay should not exceed the month of entrance and the
two following months for these provisions to be applicable.
In either case, if the case is initially processed
as being in temporary care and the stay ends up exceeding those
time lines, long term care policies shall then be applied beginning
in the third month following the month of entrance.
For all changes in financial factors, the change
will be incorporated into the appropriate eligibility base. Necessary
case action will be taken at the earliest possible time based
on advance notice requirements.
8173.5 Inter-Home Transfers - When an eligible individual moves from a Medicaid approved institution to another Medicaid approved institution, the following apply:
When both facilities have the same
level of care and the provisions of 8172.2
(1) or 8172.2 (2) (b) are applicable
for both facilities, no additional changes are necessary. The individual
is obligated for the total patient liability, but it is assigned to
the first facility that bills Medicaid for the month.
the provisions of 8172.2 (2)
(b) are applicable in the new facility only, independent living budgeting
and the new, 6 month base period are effective the month following
the month of the move. LOTC must be updated to reflect the new status
effective the date of admission in the new facility. If 8172.2
(2) (b) is applicable in the previous facility only, LTC budgeting
begins the month of entrance and the base period is shortened to end
the month before the month of change. LOTC is updated to reflect the
new status effective the date of admission in the new facility.
For transfers between facilities with different levels of care, the provisions above apply except that it is necessary to update LOTC to reflect the new living arrangement and/or level of care effective the date the new arrangement begins. The patient liability will be assigned in full to the old facility.