Adult Medicaid Manual MA-2270 LONG TERM CARE NEED AND BUDGETING

IX. REPORTING PATIENT MONTHLY LIABILITY ON DMA-5016

A. Purpose of DMA-5016

1. The DMA-5016 notifies the nursing facility of the patient's monthly liability for his share of the cost of care. There are two ways to transmit the DMA-5016 to the facility. One is an automated DMA-5016 issued by EIS. The other way is a manual DMA-5016 issued by the county caseworker.

2. For Hospice patients in a nursing facility, enter the Hospice code in EIS to ensure the automated DMA-5016 is sent to the Hospice agency.

B. Issuing a DMA-5016

1. EIS issues an automated DMA-5016 when the caseworker:

a. Enters a new pml in EIS because the a/r goes from pla (including adult care home or hospital) to a nursing facility, or

b. Increases or decreases the amount of the PML, or

c. Changes the case address, or

REISSUED 01/01/08 – CHANGE NOTICE 01-08

(IX. B. 1.)

d. Enters a new facility code, or

e. Changes the facility code.

2. The caseworker completes a manual DMA-5016 when:

a. The a/r is in 2 or more facilities in a month and each facility is due a portion of the pml. (See IX.D., below for procedures to split the PML.) Different levels of care within a hospital such as acute care and swing bed are considered two separate facilities for claims processing purposes. The total PML for the month is entered in EIS, but the caseworker must send a manual DMA-5016 to each facility to notify it of its share of the PML, OR

b. There is a deductible balance and a PML in the same month. This situation occurs when the a/r moves directly from acute care in a hospital to a swing bed within the same facility or to a separate nursing facility. Since only the deductible balance is entered in EIS, an automated DMA-5016 is not sent. The IMC must send a manual DMA-5016 to the facility to notify it of the PML. This applies even when the PML is "$0."

EXAMPLE: A/R enters hospital on 6/2 and enters nursing facility on 6/20. June is a PLA month and deductible is met on 6/2. The deductible balance is entered in EIS. On 6/20 he entered a nursing facility and PML is $0. A manual DMA-5016 is issued by the caseworker to the facility to show the a/r owes $0 PML.

3. There are specific situations in which a DMA-5016 is never sent. These occur when a case is budgeted according to PLA procedures and is authorized only for other Medicaid covered services. These situations are:

a. There is no approved FL-2 when the FL-2 is required; or

b. The a/r is under a transfer of asset sanction; or

c. The facility is not certified yet.

C. Procedures When PML Changes

1. Recipient notice requirements

a. If PML amount increases, timely notice is required.

b. If PML decreases, adequate notice is required.

REVISED 11/01/11 – CHANGE NOTICE 17-11

(IX. C.)

2. Update PML amount in EIS

a. Enter the new PML amount in EIS by:

(1) Keying a DSS-8125 prior to pull/cutoff; or

(2) Using the DB/PML transaction screen after pull/cutoff to post the pml for the next calendar month.

b. EIS will send an automated DMA-5016 to the facility.

3. Special Situations

a. If one of the following exceptions applies, notify DMA, using the DMA-5164, Change In PML Request Memo to DMA Claims Analysis Unit, (1) The recipient died and has unmet medical needs which have not previously been deducted. Revise the PML for the month of death only. [This is the only reason you can revise for unmet medical needs in month of death.]

(2) The a/r goes home unexpectedly within six months and must be rebudgeted for prior months as well as month of discharge.

(3) The a/r returns home anytime, and must be rebudgeted the month of discharge only to allow a deduction for maintenance of the home.

EIS sends an automated DMA-5016 when the Claims Analysis Section at DMA enters the change in EIS.

b. If the county dss wants to change a PML amount already posted in EIS for a previous month, the Claims Analysis Unit at DMA must give prior approval. (See V.C.10., above.) EIS sends an automated DMA-5016 when Claims Analysis keys the revision.

D. Patient Liability When A/R is in More Than One Facility in a Month - Split Liabilities

If the a/r receives care in more than one medical facility in a calendar month, it may be necessary to determine how much of the liability the patient owes to each facility. Remember that different levels of care within a hospital such as acute care and swing bed are considered separate facilities for claims processing purposes. The caseworker enters the total PML for the month in EIS and then completes a manual DMA-5016 to split the pml between the facilities.

REISSUED 11/01/11 – CHANGE NOTICE 17-11

(IX. D.)

1. A/R Does Not Have Medicare

On the first day of month, the recipient is in the:

a. Hospital-- Assign the full PML to the hospital.

b. Nursing Facility

Report the lesser of these amounts to the facility:

(1) The full PML owed each month; or

(2) The facility's Medicaid per diem multiplied by the number of days (do not count date of discharge) that the patient was in the facility.

c. The amount of the "split" PML which is reported to the second facility following a non-Medicare hospital or facility admission is:

(1) The remaining balance of the full PML after deducting the portion assigned to the first facility, or

(2) If there is no balance, zero PML.

2. A/R Has Medicare

The PML for Medicare recipients is applied only to the month of admission to a hospital because the recipient is only responsible for the Medicare deductible amount. When LTC a/r has to enter a different medical facility, follow procedures below on assigning PML.

a. Hospital

(1) Admission date is on the first day of the month

(2) Assign full PML not to exceed the Medicare deductible amount.

b. Second facility

The amount of the "split" PML which is reported to the second facility following a Medicare hospital admission is:

(1) The remaining balance of the full PML for admission month minus the Medicare deductible amount.

REVISED 01/01/12 – CHANGE NOTICE 02-12

(IX. D. 2.b.)

(2) If hospital discharge month is different from admission month, assign the full PML to the second facility for discharge month. Do not split the PML in EIS.

Example: LTC a/r with Medicare enters hospital on 5/12 and is discharged back to the nursing facility on 6/6. Assign balance of PML to hospital for May and full PML to the nursing facility on 6/6.

c. If a Medicare a/r remains in the hospital for several months, the hospital will not collect the PML. However, the actual PML must be entered into EIS.

3. If the LTC a/r is within the 21-100 days for Medicare and is moved to a second nursing facility within the same month assign number of days in the first facility times the Medicare co-payment rate to the first facility. Do not include the discharge date. This is the actual amount for which the recipient is responsible. Report the remaining balance of the PML to the second facility. Reminder: Medicare may not pay the first 100 days in every situation. Contact the facility to verify this information.

Example: LTC a/r with Medicare is in a nursing facility on 6/1. His full patient monthly liability for the month is $950. He moves to a second facility on 6/6. He is still within the 21-100 days for Medicare copayment rate to the first facility.

The remaining balance of the patient monthly liability is assigned to the second nursing facility. 5 days x $144.50 (current Medicare copayment rate as of January 2012) = $722.50. $722.50 is the patient monthly liability for the 1^st facility. Total patient monthly liability of $950-$722.50=$227.50. $227.50 is the remaining balance of his patient monthly liability, which is assigned to the 2^nd facility.

4. If a third or more facility is involved, repeat the process in IX.D.1.c. or 2.b., above, according to whether the a/r has Medicare until the PML is exhausted.

5. Do not round or drop cents.

6. Any remaining PML not collected will accumulate in the recipient's personal funds as reserve the following month.

NOTE: Flag case to check reserve monthly when the client is in danger of exceeding the reserve allowance.

REISSUED 12/01/11– CHANGE NOTICE 02-12

(IX. D.)

7. Complete a manual DMA-5016 for the split PML to each facility. Include the ending date of split PML on the DMA-5016.

8. EIS sends a separate DMA-5016 reporting the PML amount and effective date for the ongoing (next) month.