I. If an individual in a Nursing Facility
does not meet the medical need criteria, that person may still be eligible for
Medicaid coverage if the individual would be eligible if they were living in
the community. Coverage is determined using the rules in Parts 6, 7 and 10 for
an individual in the living arrangement, "living alone or with others". In this
situation, Medicaid will not pay for nursing care costs nor can they be used
toward meeting a deductible.
II.
Awaiting Placement for Residential Care (DAP or APRC). If an individual is in
need of residential care but there are no beds available the individual may
remain in the nursing facility as awaiting placement to a residential care
facility. This coverage is for individuals converting from private pay
including Medicare to Medicaid and found not in need of nursing facility level
of care. MaineCare may help the individual with the cost of care if they meet
eligibility criteria below. The Office of MaineCare Services sets the APRC
rates (Chart 3.8).
A. The Office of Aging and
Disability Services (OADS) must establish that the individual meets
non-financial criteria as identified in the MaineCare Benefits
Manual.
B. The following
financial criteria must be met:
1. the asset
and all non-financial criteria are the same as for an individual residing in a
Residential Care Facility (RCF). See Part 12;
2. countable income is determined using the
same rules as for an individual residing in a RCF; and 3. the individual's
countable income must be less than the APRC amount. A cost of care to be paid
to the nursing facility is determined using the same rules as for an individual
in a RCF. SSI and State Supplement benefits are counted when determining the
cost of care.
If countable income is equal to or over the APRC amount,
the daily rate can be used as the cost incurred for medical expenses in
determining a "spend-down" (deductible).
C. If countable income is equal to or less
than the Community Medicaid income limit for the individual's coverable group,
they can get Medicaid coverage in addition to help with the cost of room and
board under APRC.
D. If countable
income is over this amount, but less than the APRC amount, the individual is
eligible for APRC only (not Medicaid).
E. Coverage under APRC ends when:
1. the Office of Aging and Disability
Services (OADS) determines the individual no longer meets the non financial
criteria as identified in the MaineCare Benefits Manual;
or
2. the individual becomes
financially ineligible.
