Financial need is computed on the income determination screen. All income which is received or expected to be received within the eligibility base period must be considered and will be reflected on the screen unless exempted. The following guidelines are applicable.
Financial eligibility shall be based on meeting a spenddown in accordance with the independent living rules in 7530 and subsections. Charges in a non-Medicaid approved institution are not allowable to meet spenddown.
If the individual subsequently becomes eligible in a Medicaid approved facility because a current CARE assessment was completed, level of care is met, a transfer penalty expires or the facility is certified, Medicaid payment may begin to the facility. Financial eligibility is based on the provisions of and is effective the calendar month of the change from a non-Medicaid approved status to a Medicaid approved status. See 8111 and 8114.
Financial eligibility shall be determined by first computing a monthly patient liability. The patient liability is a monthly amount the individual is responsible for paying toward his or her care cost each month, if the provisions of 8172.2 (1) are met. The patient liability is the amount of income in excess of the LTC standard. As noted in 8150, all exempt and nonexempt income is considered. Where applicable, the liability should take into account the amount of any income allocation in accordance with the provisions of 8143 (4) or 8144.2. The patient liability is further reduced by allowable medical expenses.
To be allowed against the patient liability, expenses must be incurred in the current eligibility base or incurred outside of the current eligibility base and the individual was legally obligated to pay the expense on the first day of the base and such expense has not been previously applied to another patient liability, client obligation or spenddown in which the spenddown was ultimately satisfied. This includes instances when the individual has taken out a loan to pay the expense or charged the balance on a credit card. Medical bills transferred to a collection agency for repayment are considered the responsibility of the individual.
Allowable expenses can be applied to a future month's patient liability when it is not possible to account for the expenses in the month they are incurred because of the use of a one-month base period.
Medicare premiums not covered by buy-in are also allowable. See policy memo 1999-10-03, Application of Medicare Premiums to Spenddown for guidelines on applying premiums prior to accretion to buy-in. Premiums which are subject to buy-in are not allowable even if the client pays them (or they are withheld) prior to completion of the buy-in process as such amounts are subject to reimbursement to the Medicare beneficiary. Additional costs paid for Medicare Advantage policies are not reimbursed through buy-in but are an allowable medical insurance premium. Additional premiums paid by the beneficiary for Part D coverage are allowable if not subject to reimbursement by the Subsidy. This includes surcharges for late enrollment and charges to upgrade the plan above the basic level.
For nursing facility residents, items and services which are the responsibility of the facility to provide are not allowable. The NF is required to ensure that residents receive all medically necessary items, including those routine services and supplies which facilities are required to make reasonable accommodations to supply to their residents. Products which can be purchased over the counter or are regularly available without a prescription are the responsibility of the NF.
Providers are expected to stock a variety of product choices for each major type of routine supply (at least two). If a resident elects to use a product other than the similar products the NF stocks, the resident will assume responsibility for the costs of the item, but it is not allowable against the patient liability. A complete list of services which are considered the responsibility of the facility is found in the Adult Care Home Provider Manual, Section 8400. KDADS is responsible for maintaining this list. The Provider Manual can be accessed by visiting KMAP Provider Manuals.
If the individual passes the 300% special income test as described in 7430(4) and 8160(3), Medicaid coverage shall be approved if otherwise eligible and the patient liability applied. If the individual fails the 300% test, eligibility shall be determined under the Medically Needy (MN) program and the following provisions apply:
There is no coverage for nursing facility services. The estimated cost of services at the facility at the private pay rate may be applied against the spenddown.
See 7430(4), 8120(4) and 8160.
NOTE: The monthly Medicaid rate for the facility is determined by multiplying the Medicaid daily rate by 31.
A change to an established patient liability must be made prior to the first day of the base period, except as noted below, as timely and adequate notice requirements permit (see 1430 and subsections). Generally, the patient liability is finalized beginning the first day of the month the liability is effective, and no additional changes are to be made to the amount. However, the following situations must be acted upon and a liability change may result. Proper notification is issued to both the recipient and the facility:
A patient liability shall be increased by the amount of a voluntary contribution as described in 8142 (3). The increased patient liability due to application of the voluntary contribution cannot exceed the cost of care in the facility.
When circumstances change, adjustments will be made as follows (See also 2650 pertaining to CE policies for children under the age of 19 receiving non-MAGI coverage):
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.
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.
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.
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.
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.
Overstated eligibility is not considered in situations where the total client obligation is not paid out for HCBS care because the cost of services was less than the obligation.
If the HCBS recipient enters a Nursing Facility, Swing Bed Hospital, SIA (IMD* and non-IMD), or State 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.
NOTE: The age criteria policy referenced in MKEESM 8112.4 (1) are applicable to HCBS recipients that admit into an IMD or State Hospital.
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.
When an eligible individual moves from a Medicaid approved institution to another Medicaid approved institution, the following apply:
The provisions of 8172.2 (2)(b) are applicable in the new facility only, independent living budgeting and the new, 6-months 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.