Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 20 - Division of County Operations
Rule 016.20.99-012 - MS 99-8: Earnings of ICF/MR Residents - Changes to the Medical Services Policy manual to allow residents of ICF/MR facilities to keep all of their earnings up to an amount equal to the current SSI SPA
Current through Register Vol. 49, No. 9, September, 2024
3000 Guidelines for the Long Term Care Program and Other AABD
Categories
3100 General Information
3110 Facilities Which Provide Services
Facilities which provide medically necessary care and services 24 hours per day on a long term basis include private nursing facilities, Benton Services Center, Arkansas Human Development Centers, private intermediate care facilities for the mentally retarded (ICF/MR's), and ICF/HR facilities with both over and under 15 beds.
3120 Services Provided Under Medicaid
In addition to facility vendor payments, all services listed in the pamphlet, "Your Guide to Medicaid Services in Arkansas", are available to individuals under the Long Term Care Program, with the following exception: Individuals in the State Human Development Centers are not eligible for the Prescription Drug Program.
3130 licensing and Classification of Facilities
To receive vendor payment under the Medicaid Program, a facility must be licensed and certified by the Office of Long Term Care (OLTC), and must execute a provider agreement with the Division of Medical Services.
The OLTC publishes a directory listing all participating facilities. Changes to the directory are issued periodically. The directory and updates are provided to each county office.
3135. Nursing Facility
Section 1919 (a) of the Social Security Act defines a nursing facility as an institution which is primarily engaged in providing:
Skilled nursing care and related services for residents who require medical or nursing care,
Rehabilitation services for the rehabilitation of injured, disabled, or sick persons, or
Health-related care and services to individuals who because of their * mental or physical condition require care and services (above the level of room and board) which can be made available to them only through institutional facilities,
and is not primarily for the care and treatment of mental diseases.
»
3140 Personal Allowance for Facility Residents
Each recipient in a facility is allowed to retain $40 per month from their income for personal expenses. (EXCEPTION: Recipients whose only income is SSI will have their monthly payment reduced to $30. They are allowed to keep this amount as a personal allowance.) Upon written authorization of a resident, the facility must hold, safeguard and account for the personal funds of the resident deposited with the facility. If the resident's personal funds are in excess of $50, the facility must deposit the funds in excess of $50 in an interest bearing account (or accounts), separate from any of the facility's operating accounts, that credits all interest earned on the resident's account to his or her account. A resident's personal funds may not be commingled with facility funds or with any person's funds other than another resident. The resident's individual financial record must be available on request to the resident or his/her legal representative.
1 In addition to the $40 personal needs allowance, ICF/MR residents, including residents of State Human Development Centers, who have income from employment are allowed to keep all of their earnings up to an amount equal to the current SSI SPA.
A resident with earnings who is receiving intermediate care in a nursing facility may keep up to $100 increased personal needs allowance if his/her physician has stated that a period of employment activity is necessary as a therapeutic or rehabilitative measure. If a resident receiving skilled care in a nursing facility becomes employed, the Utilization Review Section of the OLTC should be contacted and requested to reevaluate medical necessity.
Certain SSI recipients whose stay in a nursing facility is not expected to exceed 3 months and who have a home to maintain will be allowed to retain full SSI benefits for personal expenses for three calendar months following the month of entry. The SSI payment, in these instances, will not be considered in eligibility or payment determination (Re. MS 3401).
A $90 personal needs allowance will be given to a veteran receiving a VA pension in a facility who has no spouse or dependent children. A veteran's surviving spouse who has no dependents and who receives a VA pension will also be given a $90 allowance. The full $90 allowance will be allowed only when VA has reduced the pension to $90. (Re. MS 3348.1). Veterans receiving VA compensation do not qualify for the $90 PNA.
3150 Special Charges to Recipients in Facilities
The facility must inform the patient prior to or at the time of admission or application, and during his/her stay, of services available in the facility and of related charges, including charges for services not covered by Medicare or the per diem rate. Recipients may be charged only for optional services (services * not necessary or consistent with the normal care of the patient). When such services are provided, documentation must be on file with the OLTC. -The refusal of a recipient to accept optional services offered by a facility must not effect a decrease or alteration in the services required or necessitated by his/her condition or otherwise considered as normal care. Inquiries from recipients or family members concerning special charges will be referred to the OLTC.
3160 Nondiscrimination
The Division of County Operations complies with all provisions of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, and the
Americans With Disabilities Act of 1990. All facilities authorized to participate in the LTC program must also comply with these provisions. No person will be prevented from participation, denied benefits, or otherwise subjected to discrimination based upon race, color, sex, national origin, disability, age, religion, political affiliation, or veteran status.
The Division of County Operations has the'responsibility of informing applicants and recipients that assistance is provided on a nondiscriminatory basis and of their right to file a complaint with the Division, the Department of Health and Human Services, the Department of Justice, and/or the United States Civil Rights Commission if they feel they have been discriminated against on the basis of one of the above.
The OLTC is responsible for securing a statement of compliance from all hospitals and facilities authorized to participate in the Medicaid program, and for assuring that the Statement of Compliance is officially adopted and posted on the premises. The OLTC will also assure that copies of the policy are provided to all employers and staff, and to all referral agencies. The OLTC will conduct annual reviews of facilities to insure compliance with these provisions.
3170 Freedom of Choice
Residents of nursing and ICF/MR facilities, and AABD recipients whose primary insurance is Medicare, are not required to participate in the Medicaid Primary Care Physician Managed Care Program.
These recipients will have freedom of choice in the selection of facilities, physicians, pharmacies, and other medical providers. The recipient should be informed that payment under the Medicaid program can be made only to medical providers authorized to participate in the Medicaid program. If the recipient wishes to utilize the services of a personal physician or other medical practitioner who does not participate in the Medicaid program, the recipient will be advised that payment cannot be made by the Agency for these services, and that the cost will be his/her responsibility.
3180 Placement
Relatives or friends of a facility applicant should help in making the selection of a Medicaid certified and licensed facility. Names and addresses of facilities that can provide the appropriate care and services will be given to the patient or his/her family.
If the applicant is unable to make this choice and if there are no relatives or friends to assist in the decision, the county office will assist with the placement. If placement cannot be made, a request for assistance should be made to the OLTC.
3200 Application Process
3210 Initial Application for Facility Payment
An application for facility services may be made by the applicant, designated representative, next of kin, or person(s) acting responsibly for the individual. Applications should be made in the county where the facility chosen by the individual is located. If an application is made in the applicant's home county
-before facility entry, but the applicant enters a facility in another county, the
-application will be denied by input to WIMA, using denial Reason 53. A DCO-700 will then be completed, advising the client or the representative that the application has been sent to the appropriate county. All records will then be
transferred to the county where the facility is located. A new application will not be needed by the receiving county, and the original date of application will be entered in ACES when the application is reregistered.
NOTE* If a period of eligibility has been, or will be, established in a facility in the county of initial application, that county will certify the case for the eligible period before transferring the case to the second county.
Annlications may be processed for deceased persons. Application may be made by any person with responsibility for the medical debts of the deceased person.
Amplication for facility services will be made on Form DCO-777. This form will be completed for all applications for facility vendor payment unless the individual is currently receiving assistance as an AFDC, U-18, or Foster Care (Cat. 91 or 92) recipient. No new application is needed for these categories.
3220 Reapolication for Facility Payment
Rpannlication for facility services is made in the same manner as initial
annlications Previous records will be reviewed. If the applicant comes from
another county where his case was closed, the record will be secured from that
county.
3230 Distinction Between Application and Inquiry
Every person has the right to apply for Medicaid. No application or inquiry may be ignored.
The distinction between an application and an inquiry is as follows:
3240 Steps in Application Process
3241 Initial Contact
Initial contact may be made in person, by telephone, or by letter. Contact may be made by the applicant, a designated representative, the next of kin 0 another person acting responsibly for him. The following tasks will be comp-Hted by the county worker during the initial contact:
-Tprm Care-Utilization Control Committee for all facility applicants. If the applicant has not selected a facility, a DCO-703 will be given or mailed to the applicant or his representative for him to take to his
in the advance notice that the case will be closed and that a new application will be required to reopen the case.
Anticipated income changes that will not result in case closure may be entered in WNHU no earlier than the month prior to the month of receipt of the income. The vendor payment adjustment will then be made by the Medicaid claims processing agent (Re. DCOUM 3723 for procedure). The recipient or representative should be notified of the increased vendor payment responsibility by DCO-700 at least ten days prior to input of the change.
As with regularly received non-monthly income, if benefits will be terminated for only one month for receipt of irregular non-monthly income, a new application will not be required and the customer will be so advised. Closures of two or more months will require a new application.
When SSA lump sum benefits result in income ineligibility, the case will be suspended in the month of receipt of the lump sum. A new application will not be required to reopen the case in the following month. (Re. MS 3634.1 for procedures).
Interest and dividends willbe considered in both eligibility and net
income determinations. Anindividual will not be allowed to retain
interest and dividends forpersonal needs in addition to the monthly personal needs allowance.
In determining initial eligibility and at subsequent revaluations, the latest interest/dividend statement (two if paid quarterly, at least three
if paid monthly) will be used to determine the countable monthly amount. If small interest/dividend amounts paid monthly or quarterly fluctuate slightly, counties may average and use the the average amount until the next scheduled reevaluation, unless an adjustment is necessary sooner due to a reported change. Interest/dividends credited or paid annually will be counted as income in the month of credit or receipt.
The county worker will provide the customer (or authorized representative) with an explanation regarding the consideration of interest/dividend income in the eligibility and net income determinations. Since the monthly interest/dividend amount will be combined with other income before the $40 monthly allowance for personal needs is considered, the recipient will not receive the full $40 monthly allowance unless he/she withdraws the interest/dividends as paid.
NOTE: Interest income of State Human Development Centers and Benton Services Center customers will be used in determining initial eligibility, but will not be considered in determining net income. All recipient interest income will be reported by these facilities in their semi-annual cost reports, and the full amount will be deducted by Central Office at the time of retrospective cost settlement.
* Interest income of customers in 10 bed ICF/MR facilities is counted in BOTH initial and post-eligibility determinations, as semi-annual cost reporting is not done for these facilities.
3342 Consideration of Ineligible Spouse/Parentfs) Income after Initial Eligibility Has Been Established
After initial eligibility has been established, income of the noninstitution-alized ineligible spouse/parent(s) may be considered available to the eligible spouse/child in a facility only to the extent that it is voluntarily contributed either to the eligible spouse/child in a facility or directly to the facility for partial vendor payment.
The ineligible spouse/parent(s) is not required to make a contribution to the eligible spouse/child in a facility or to the facility and may, in fact, choose to make no contributions.
If, however, the ineligible spouse/parent(s) indicates that he/she will voluntarily contribute any income, determine whether the contribution is made directly to the eligible person in the facility or directly to the facility for partial vendor payment.
Contributions made directly to the eligible person in the facility will be considered as unearned income both in determination of eligibility and in determining the net income to be applied to the vendor payment.
Contributions made directly to the facility as partial vendor payment will only be considered for the individual's share of the facility vendor payment, and . will not be considered for recipient eligibility. The payment made by the
ineligible spouse/parent(s) must be for covered services under the LTC program to be considered available to apply toward the vendor payment. Payments made by the ineligible spouse/parent(s) for special charges or additional services and items not covered by the facility vendor payment will not be considered. This includes payments made by the family of the facility recipient to the facility for the cost of a private room.
Each ineligible spouse/parent will be advised that income contributions may be made on a voluntary basis to the eligible spouse/child in a facility or to the facility, and of the different ways that the contributions may be considered. The decision of whether to contribute or not is left to the ineligible spouse/parent(s) to make, and no suggestions or recommendations of action will be given. Any questions that the ineligible spouse/parent(s) has regarding the effects of a specific action will be answered.
Non-voluntary contributions can only be effected by court order, and only considered when actually paid by the ineligible spouse/parent(s). The eligible person in a facility is not required to seek support from the ineligible spouse/parent(s) to remain eligible for facility care.
3343 Determination and Verification of Earnings from Employment
The monthly gross amount of any earnings from employment will be determined. Monthly gross income is determined by the actual earnings received (or to be received) during the month of application or reevaluation, whether paid weekly, biweekly, semimonthly, or monthly. In cases where 5 pay periods during the month of application result in ineligibility, the application will not be denied (if otherwise eligible) but will be considered for eligibility in the following month when there will be only 4 pay periods. In ongoing cases where earnings are biweekly, the cases will be flagged (by DCO-88 or WALR) to make income adjustments on WNHU during the months when 5 paychecks are to be received.
If the earnings fluctuate, the worker will determine, by averaging or other
means, an amount which fairly reflects the income actually currently available
\ to the applicant on a monthly basis. The case narrative will clearly reflect
" the manner in which the income was determined and the justification for
considering it a fair reflection of the actual, current income available to the
applicant.
Verification of earnings from employment will be by check stubs, pay slips, or collateral contact with the employer. Sufficient verification must be obtained so that the actual income of the employee can be determined. The worker will not automatically assume that one check stub accurately reflects earnings for an entire month. The latest month's verification will be required. If a person is paid weekly, then the latest 4 (or 5) consecutive check stubs will be required. If the person is paid every other week or twice a month, then the latest two check stubs will be required, and if paid monthly, then the latest check stub will be required. If the customer does not have the required verification, then verification from the employer will be required:
EXCEPTION: For cases in which the applicant/recipient has just begun employment and a month's verification is not available, the county worker wi 11 compute the i ncome from the best information available. In this instance the case will be flagged for a redetermination of earnings in the following month using full verification procedures.
3343.1 Earnings of ICF/MR Facility Residents
*Residents of ICF/MR facilities, including residents of State Human Development Centers, who have earned income may be given an earnings disregard of up to an amount equal to the current SSI SPA in addition to the $40 personal needs allowance. Nursing facility residents with earnings who receive intermediate care may be given a disregard of up to $100 of their monthly earnings, provided there is documentation that a physician has prescribed employment activity as a therapeutic or rehabilitative measure. If a nursing home resident receiving skilled care reports earnings, the Utilization Control Committee of the OLTC should be contacted and requested to reevaluate medical necessity.
All nursing facility and ICF/MR residents must first pass the gross income test, with no disregards allowed. If found eligible, the consideration of earnings will be as follows.
*Earnings of residents of these facilities must be taken into consideration for both eligibility and net income determinations. If residents pass the gross,income eligibility test, their earnings will be included in the net income determination. In determining the net income to be applied toward the vendor payment, first subtract the mandatory deductions {e.g., federal and state income taxes) from gross income and, from the remaining earned income, up to an amount equal to the current SSI SPA for personal needs. Refer to MS 3400 for consideration of earnings at certification.
If the earnings of ICF/MR facility residents stay below the SSI SPA, no reporting of fluctuations is needed.
The facility administrator will report to the county any month in which a resident's earnings exceed the SSI SPA.
y If earnings consistently stay above the SSI SPA, they may be averaged (MS 3343), provided the facility administrator will agree to report to the county:
3344 Determination and Verification of Earnings from Farm. Business
or Self-Emplovment
Generally, it is necessary for the self-employed individual to estimate current income based on a projection from the tax return filed for the previous year and from current records kept in the regular course of business.
Because of the fluctuating nature of income receipts and self-employment expenses, current estimates for net income from self-employment will be based on the entire taxable year.
3344.1 Determining Amount of Net Earnings from Self-Employment
The amount of net earnings from self-employment is not always ascertainable from business records. If this is the case, use the first of the following methods that is likely to give the most accurate estimate of current and future net earnings which may be allocated on a monthly basis.
After the estimated net income from self-employment has been determined, explain to the individual how it has been determined and the effect it has on eligibility. Advise the individual that he/she may appeal if he/she disputes the estimates, or that he/she may request a change or reapply if new evidence becomes available.
If the allocated amounts of income result in ineligibility, explain to the individual that he/she may reapply if the remaining current year receipts or expenses or a new accounting of net earnings from self-employment result in lower net earnings.
If the individual is eligible for assistance, advise him/her that any substantial variation of net earnings should be reported promptly with appropriate evidence, so that overpayments and underpayments can be prevented. Explain also that he/she must provide a copy of the federal tax return as it becomes available.
When one of the methods under items 3, 4 or 5 has been used to determine net earnings, advise the individual that he/she should maintain monthly records of ongoing receipts and expenditures until the federal tax return is available so that substantial variations of income can be identified and reported immediately to avoid erroneous eligibility.
3344.2 Unstated Income
Unstated income is income not reported or otherwise accounted for, but known to exist because living expenses exceed the income that has been reported.
An applicant, recipient or person whose income is subject to deeming may have unstated income.
The amount of unstated income to be considered as unearned income in determining eligibility is the difference between the declared monthly income and the monthly living expenses.
3344.3 When to Develop Unstated Income
When an individual's stated income does not appear adequate to cover living expenses, it will be necessary to develop unstated income, unless there is a reasonable explanation to account for the difference; e.g., savings have been used or bills have not been paid.
If the previous year's income tax return of an individual engaging in self-employment activity shows "0" or only a small amount of net income, living expenses and unstated income must be explored.
3344.4 Development of Living Expenses
When development of living expenses is required due to unstated income, explain to the individual what information will be needed to develop living expenses and why it is needed. Consider the living expenses of each and every member of the self-employed individual's household, and explain that all expenses must be considered. It is essential that a complete disclosure be obtained.
The following guide should be used in developing living expenses: *
3344.5 Determination of Unstated Income
Reported income is the aggregate of unearned and earned income of the following people living together as one household.
amount of reported monthly income be subtracted from the amount of monthly living expenses, and the result, if greater than zero, be added to the amount of total unearned income of the applicant(s). Such income would be treated as other unearned income in the application.
EXAMPLE: The applicant reports earned income consisting of $100 per month net earnings from self-employment. The spouse, also an applicant, reports a pension of $100 per month. Living expenses are developed and total $400 per month. The total family income of $200 is subtracted from the $400 monthly living expenses, leaving $200 that will be counted as unstated unearned income for the couple to be divided as $100.00 for each member of the couple.
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eligibility start and stop date for a fixed period. If the level of care review date is not a future date when a case is to be added on WNHU, a later DCO-704 must be requested from the OLTC Utilization Control Committee. When Utilization Control completes another level of care review prior to county request and/or certification of a case, the later DCO-704 will be automatically forwarded to the county office.
Once the level of care, the level of care begin date, and the level of care review date, when appropriate, have been entered in WNHU at certification, the county office will not make any later changes to these fields. Any changes in the level of care, decision date, and review date will be processed centrally by OLTC and the Medicaid claims processing agent.
If a Medicaid recipient in a facility elects hospice care after a case has been certified by the county with a level of care code S, A, B, C, or D, the code will be system changed by OLTC, and the county will not be involved.
The county offi ce i s respons i bl e for compl eti ng part III of the DCO-704 and distributing the DCO-704 to the appropriate parties at the time facility eligibility is authorized via the DCO-57 or DCO-765.
3351 Prompt Notice of Skilled Care Classifications
In any case that the county office cannot complete certification action promptly after the receipt of a DCO-704 which indicates a skilled care classification, the county worker will provide a machine copy of the DCO-704 to the facility where the patient is residing. This copy will be annotated with the following information at the top of the
form:
"Information Copy for Utilization Control Requirements Only" and the name of the facility.
3352 Appeal of Utilization Control Committee Action There are two types of appeal in the Utilization Control process:
\ case where admission/continued stay is determined not to be medically necessary. However, if the committee's decision is that continued stay is not medically necessary, this decision is final. The committee will make notification to the attending physician, the facility administrator and the county office when it has been determined that continued stay in a facility is not medically necessary.
If the county office has a pending application, it will be denied (MS 3500).
If the recipient has an active case, the county office will provide advance notice of closure to the recipient and next of kin (when possible) by form DC0-700 and, at the end of the notice period, close the facility case by submitting a DCO-57 and/or DCO-765 with appropriate entries for data entry.
3400 Determination of Net Income
When categorical eligibility and medical necessity have been established, the county worker will determine the amount of the individual's income that will be applied to the cost of care. Section 3 of the DCO-707 (and the DC0-712 when there is a CS) is used for the determination.
Using Section 3 of the DCO-707, determine the income to be applied to the cost of care as follows:
In Section 3, enter all income of the recipient by type and amount, with the following exception:
For State Human Development Centers (HDC) and Benton Services Center (BSC) residents do not enter the interest income. A semi-annual cost accounting will be made by these facilities which will take this income into consideration.
Enter the unearned income of all recipients. Exclude VA Aid and Attendance payments and VA CME/UHE, along with the interest income of HDC and BSC residents.
* From the earned income of all recipients deduct the actual mandatory deductions and work related expenses from gross earnings. From the earnings of 10 bed ICF/MR residents and State Human Development Center residents, an additional amount up to the current SSI SPA may be deducted from earned income as a personal needs allowance.
Total the unearned income and the net earned income and enter on Line 4.
For individuals whose cases were certified prior to November 1, 1995, deduct the fees which were approved - trustee fees, attorney fees, monthly bank services and preparation of income tax returns. Cases certified November 1, 1995, and later may have deducted ONLY the monthly service charges for maintaining the bank account.
Effective 11/1/1995, it will NOT be the responsibility of the county to attempt to identify individuals who may be eligible for a $90 PNA or to allow a $90
PNA when the VA benefits have not been reduced to $90. If a single veteran or surviving spouse of a veteran with no dependents is receiving VA pension and the benefits have not been reduced to $90 at certification, only a $40 PNA will be given. The case will later be adjusted if the county learns that the pension has been reduced to $90.
Individuals previously given $90 PNA and still receiving the full VA pension amount will be reduced to a $40 PNA at next case change or reevaluation after appropriate notice. They may be instructed to contact the Veterans Administration if they believe they are entitled to a $90 reduced pension.
If the individual has no spouse and/or dependents or noncovered medical expenses, this will be the only allowance given to arrive at net income. If the individual has dependent children only (no spouse), proceed to step 4 below before arriving at net income. If the individual has a spouse or a spouse and other dependents living in the community, refer to MS 3338.3.
Eligibility for the individual in a facility must be established before consideration is given for protected maintenance. If there are dependent (under 18) children, the combined income of the children must be less than the Medically Needy Income Level for the appropriate number of children in the household (MS 7610) to qualify for protected maintenance.
In addition to meeting the stated income limitations, the countable resources of the dependent children must be within the AABD resource limitations to qualify for protected maintenance. Actual amounts allowed for protected maintenance are determined as follows:
After deduction of the personal needs allowance and a maintenance allowance (if any), the total of noncovered medical expenses (for the facility recipient only) will be entered on the DCO-707. For noncovered medical expenses allowable as deductions, refer to MS 3338.3 #4. The remaining amount, after all allowable deductions, is the net income that the individual will be expected to apply to the cost of care.
* When ready to certify a case, a total of the excluded earnings,income trust fees (when applicable), maintenance allowance(s), and noncovered medical expenses (if any) will be entered in the PROT MAIN Field of the DCO-57 or DCO-765. The net amount remaining will also be entered on the DCO-57 or DCO-765. The actual vendor payment will be determined centrally by the Medicaid claims processing agent, based on the net income that has been entered by the county office.
VA PENSIONS REDUCED TO $90
For active cases, ONLY after the VA pension benefit has been reduced by VA to $90, $90 will be entered on WASM in the VA PENSION field. On WNHU, $50 will be entered in the PROTECTED MAINT. field (plus any additional amount considered for noncovered medical expenses). The system will automatically exclude the $40 PNA so that a total of $90 will be given to the veteran or surviving spouse.
3401 Treatment of Extended SSI Benefits for Institutionalized Recipients
Effective 7/1/88, those SSI recipients entering a medical or nursing facility:
o who have a home to maintain, and
o who obtain a medical statement for SSA to document that the medical confinement will not exceed 3 calendar months after the month of entry to the facility
will be allowed to retain their full SSI benefits for a period up to 3 full months. \ No extension beyond the 3 months will be allowed.
When aware of the extension of SSI benefits for facility applicant/recipients, the county office will totally disregard the SSI benefits for determination of facility eligibility and vendor payment. If the applicant/recipient has income from any other source (e.g. VA, SSA, RR Retirement, etc.), that income will be included in the facility budget.
At certification of facility applicants receiving the full SSI benefit (who have no other income), only the $30 personal needs allowance will be entered on the DCO-57 (WNHU) and the remaining income will be disregarded.
When certifying recipients with a combination of SSI and other income, all of the SSI benefit will be disregarded. The other income will be entered in tjie budget section of the DCO-57 (WASM) and DCO-765 (WNHU). The $40 personal needs allowance will be deducted from the countable income, and the remaining income will be entered as NH Net Income (patient liability) on the DCO-57 or DCO-765 (WNHU).
3500.1 Certification of Patients Approved for Medicare
When Medicare approves individuals for skilled nursing care/extended care, the facility receives reimbursement in the form of Medicare per diem and Medicaid coinsurance (if applicable) for up to 100 days, provided the individual continues to meet Medicare criteria.
Applications for Medicare approved admissions will be processed in the same manner as applications for non-Medicare approved admissions, except that nursing home services will not be authorized on WNHU until Medicare benefits have been exhausted. Medicaid for Medicare eligible individuals will be authorized on WASM, however, so that all other Medicaid covered services may be paid. For example, Medicare pays 100% of facility expenses for only 20 days. After this time, the individual becomes liable for coinsurance, which cannot be paid by Medicaid until the case is opened on WASM.
The monthly Medicare per diem amount will not be considered when determining income eligibility, but it will be treated as a third party resource to be applied to the cost of care in a facility.
When Medicare approves an individual for skilled nursing care, the facility should notify the county office of the Medicare admission via the DCO-702.
If at some point the individual fails to meet Medicare criteria or exhausts his/her benefits, Medicare will stop payment. The facility will notify the county office of the change in status via the DCO-702. On the day following termination of Medicare benefits, the Service Representative may authorize facility services on WNHU to be effective on that date, provided the individual continues to meet all LTC requirements.
3600 Continuing Eligibility
Reevaluation of facility cases to determine continuing eligibility is required periodically by the county office for all categories of LTC. Once a case has been \ certified, the county office responsibilities will be limited to completing regularly scheduled revaluations, making retroactive and current income adjustments on WNHU, transferring cases, and effecting closures due to death, discharge or other eligibility factors.
3610 Reevaluation of Eligibility
The time period for review of facility cases will vary according to the category, as shown below. All facility cases, regardless of category, must be reviewed within 30 days of receipt by the receiving county when a case transfer has been made to assure continuing eligibility. However, a new application and full reevaluation is not required unless it is time for the annual reevaluation.
3611 Foster Care (Cat. 91 or 921 and U-18 Cases I
These cases will be reevaluated every six months. Eligibility will be redetermined according to the current eligibility criteria for the category. Form DCO-95 will be completed (DCO-98 for Cat. 92, IV-E foster children), along with other required forms.
3613 SSI
These facility cases will be reevaluated every twelve months. Form DCO-777 and all other required forms will be completed. Categorical eligibility is established if the individual continues to receive SSI payment.
3614 AA. AB. and AD
These cases will be reevaluated every twelve months. Form DCO-777 and all other required forms will be completed, and eligibility will be redetermined according to the current AABD criteria. NOTE: If the individual has a spouse and/or other dependents in the community and fluctuating noncovered medical expenses, a partial reevaluation will be completed every 6 months, if the county has elected to estimate net income (Re. MS 3338.4),
3615 Completion of Reevaluation
Upon determination of continuing eligibility, the DCO-57 will be completed for data entry into WASM. An "0" action will be shown along with worker number, date of completion of review, and any changes.
WNHU update will be made only if there have been changes in income, NH county or NH number. If income has changed, NL must be entered as the Action Type on WNHU.
If an income change was not previously reported, the retroactive income with start and stop dates will be entered in the retroactive payment section of the DC0-765 or DCO-57 for WNHU update. If the last income change is the current income, however, this change will be entered as a current change with an income start date effective the month the new amount was received (i.e., do not use a retroactive field).
* Residents of the State Human Development Centers will report only current (i.e., past month's) earnings at reevaluation. They will not verify all earnings received since the last reevaluation was completed. No retroactive adjustments will be needed.
If an HDC resident ever has monthly earnings that exceed the SSI SPA, the facility will report this to the county office so an adjustment can be made on WNHU.
The DCO-87 will be coded for next anticipated change/reevaluation, and the DC0-88 will be marked to show the reevaluation was completed.
3620 Utilization Control
The Utilization Control Committee of the Office of Long Term Care will periodically review and redetermine patient classification and necessity for continued stay in a facility when required. Classification and medical necessity reviews will be made only for individuals whose medical condition changes and for those admitted for convalescent care.
When the need for continued stay in a facility has been determined to be medically necessary, a new review date is assigned and the approval/patient classification is valid through that date. The county office will not receive notice of change in classification, unless a change in medical necessity will require case closure, or transfer to another facility. The change in classification (if any), the decision date, and the new review date will be system entered by OLTC.
3343.1 Earnings of ICF/HR Facility Residents
*Residents of ICF/MR facilities, including residents of State Human Development Centers, who have earned income may be given an earnings disregard of up to an f) amount equal to the current SSI SPA in addition to the $40 personal needs v allowance. Nursing facility residents with earnings who receive intermediate
care may be given a disregard of up to $100 of their monthly earnings, provided there is documentation that a physician has prescribed employment activity as a therapeutic or rehabilitative measure. If a nursing home resident receiving skilled care reports earnings, the Utilization Control Committee of the OLTC should be contacted and requested to reevaluate medical necessity.
All nursing facility and ICF/MR residents must first pass the gross income test, with no disregards allowed. If found eligible, the consideration of earnings will be as follows.
*Earnings of residents of these facilities must be taken into consideration for both eligibility and net income determinations. If residents pass the gross income eligibility test, their earnings will be included in the net income determination. In determining the net income to be applied toward the vendor payment, first subtract the mandatory deductions (e.g., federal and state income taxes) from gross income and, from the remaining earned income, up to an amount equal to the current SSI SPA for personal needs. Refer to MS 3400 for consideration of earnings at certification.
If the earnings of ICF/MR facility residents stay below the SSI SPA, no reporting of fluctuations is needed.
The facility administrator will report to the county any month in which a resident's earnings exceed the SSI SPA.
If earnings consistently stay above the SSI SPA, they may be averaged (MS 3343), provided the facility administrator will agree to report to the county:
3344 Determination and Verification of Earnings from Farm. Business
or Self-Employment
Generally, it is necessary for the self-employed individual to estimate current income based on a projection from the tax return filed for the previous year and from current records kept in the regular course of business.
Because of the fluctuating nature of income receipts and self-employment expenses, current estimates for net income from self-employment will be based j on the entire taxable year.
