Adult Medicaid Manual MA-1100 SSI MEDICAID-COUNTY DSS RESPONSIBILITY

IV. COUNTY DSS RESPONSIBILITY when AN SSI RECIPIENT enters LONG TERM CARE (LTC)

When an ongoing SSI recipient enters long term care (or psychiatric residential treatment facility (PRTF) if under 21), SSA continues to determine Medicaid eligibility. However, the recipient or his representative must contact the county dss and request payment for nursing home cost of care. Payment for nursing home cost of care is not an automatic benefit for SSI Medicaid recipients. In order to establish eligibility for cost of care, the county dss must consider the following:

• County of residence
• Patient Monthly Liability (PML)
• Level of Care (FL-2/MR-2) – Not applicable to PRTF (Refer to MA-2270, Long Term Care Need And Budgeting)
• Transfer of Resources – Not applicable to PRTF as transfer of resources sanctions apply only to nursing facility expenses, CAP waiver program, and in-home health services and supplies. See MA-2240, Transfer of Resources, for the definition of in-home health services and supplies.
• Community Spouse and dependents income allowance
• Community Spouse Resource Protection

Inpatient treatment in a psychiatric residential treatment facility (PRTF) is a covered service for individuals under 21. The claims are paid the same way as for a nursing facility. Admission to a PRTF is treated as an admission to a nursing facility for budgeting purposes.

Take the following steps to determine if an ongoing SSI Medicaid recipient is eligible for payment of cost of care:

A. Establish County of Residence

Refer to MA-2221, County Residence.

1. If the recipient has established residence in another county, or the SDX shows the incorrect county of residence, refer the a/r to the correct county to request cost of care.

2. If the recipient last lived in pla outside of North Carolina, the county of residence is the county where the a/r resides in the nursing facility.

3. If there is a conflict in county residency, refer to MA-2221, County Residence.

REVISED 11/01/11 – CHANGE NO. 17-11

(IV.)

B. Establish a Case Record

When county residency has been established prepare a county case record. Include in the record all forms and documents identified in this section.

C. Establish Level of Care. (Refer to MA-2270, Long Term Care Need and Budgeting.)-Not applicable to PRTFs.

1. Request a completed FL-2/MR-2. Use the MR-2 to request the level of care for ICF-MR and CAP-MR/DD.

2. Send the FL-2 to the Claims Processing Contractor Prior Approval Unit and forward the MR-2 to the Murdock Center, Specialized Services, to obtain prior approval.

3. If the recipient does not have an approved FL-2/MR-2 for the correct level of care, do not authorize payment for cost of care.

D. Complete the Adult Medicaid Applications and Supplement B - LTC Budgeting

1. It is not necessary to complete sections already verified by SSI eligibility (i.e. citizenship, age, disability, etc.).

2. Evaluate for transfer of resources.

Transfer of Assets reports are received by DMA from SSA and sent to the counties to evaluate an SSI individual for transfer of resources. SSA enters a payment status code of N04 to indicate excess resources, but not necessarily due to a transfer. Additional investigation may be necessary to ensure it was not a transfer that created a period of ineligibility. React to reports upon receipt. Refer to MA-2240, Transfer of Resources.

a. If a non-allowable transfer has occurred, follow transfer of resources policy. Assign sanction, if appropriate.

b. Do not authorize cost of care during sanction period.

3. If the recipient has a community spouse, determine spousal and dependent family member allowance.

4. Establish that reserve is within allowable limits. If countable assets exceed the reserve limit for one and cannot be reduced by the burial exclusion, do not authorize cost of care. (If resources have not been reported to SSA, use the DMA-5049, Referral to Local Social Security Office, to advise SSA.)

REISSUED 11/01/11 – CHANGE NO. 17-11

(IV.D.)

5. Determine PML per MA-2270, Long Term Care Need and Budgeting.

a. The PML is “0” for the month of entry.

b. Do not count the SSI payment when determining the PML.

E. Individual Ineligible for Cost of Care

If the individual is ineligible for payment of cost of care due to inappropriate level of care, transfer of assets sanction, or excess reserve, send a DSS-8109/DSS-8109S, Notice of Benefits Denied or Withdrawn, to deny payment for cost of care.

F. Individual Eligible for Cost of Care

When it is established the recipient is eligible for payment of cost of care, take the following steps:

1. Update the following fields in EIS:

a. County Number

b. District # and Worker #

c. Address

d. Maintenance Allowance

e. Earned Income, Unearned income, Total Countable Income

f. PML

g. Medicaid Effective Date

h. Living Arrangement Code

2. Complete and send the DMA-5016, Notification of Eligibility for Medicaid/Amount and Effective Date of Patient's Liability, to the facility. Ensure the PML reported to the facility agrees with the PML in EIS.

3. Send a DSS-8110/DSS-8110S, Notice of Change in Benefits, to notify the recipient he is eligible for payment of cost of care. Also use the DSS-8110/DSS-8110S, Notice of Change in Benefits, to:

a. Advise him that if his SSI terminates, his cost of care will also terminate.

b. Instruct him to notify the dss of any change in living arrangement or if his SSI terminates.

REVISED 10/01/05 – CHANGE NO. 28-05

(IV.)

G. Review

As long as the recipient continues to receive SSI, the county dss does not have to redetermine eligibility. If the dss learns of a change that might affect eligibility for cost of care or the PML, treat as a change in situation. If the change affects eligibility for SSI, use the DMA-5049, Referral to Local Social Security Office, to report the information to SSA. Examples of when the dss must react to an SSI recipient in LTC: individual leaves the facility, changes level of care, COLA increase, change in income other than SSI, or a countable asset is discovered that was not previously considered.

H. SSI Recipient in LTC Returns to PLA

If an SSI recipient leaves LTC and returns to a private living arrangement, change the living arrangement code in EIS to reflect pla living arrangement. EIS will use the county and address on the SDX.

I. SSI Recipient in LTC Transfers to Domiciliary Facility

If an SSI recipient in LTC transfers to a domiciliary care facility, refer to the Special Assistance Manual to authorize the SA payment.