Special Assistance SA-3310 CHANGES IN SITUATION

III. CHANGES FOR ONGOING CASES

A. Change of Address/Living Arrangement

1. From SA facility to SA facility

a. Verify and document change.

b. Verify new facility code in EIS.

c. Complete the DSS-8125, EIS data screen.

2. From SA facility to Private Living

a. Verify and document change.

b. Send the DSS-8110, Your Benefits Are Changing (Timely), to terminate Special Assistance payments observing required time frames. Refer to SA-3330, Notices.

(1) For SSI recipients, transfer to MA per instructions in EIS. Complete and send DMA-5049, Referral to Local Social Security Office, to SSA.

(2) For non-SSI recipients, always evaluate for potential Medicaid eligibility and other programs of assistance.

c. Determine amount of SA overpayment owed by the recipient.

(1) Apply 5/10 day rule. Using a calendar, count 5 calendar days beginning the day following the date the change occurred and add 10 working days.

(2) Subtract the date determined by applying the 5/10 day rule from number of days in the month.

(3) Divide the recipient's monthly SA payment minus the $46 personal needs allowance (PNA) by the number of days in the month to determine the per diem rate for that month.

(4) Multiply the number of days of recoupment times the per diem rate to determine the amount of SA overpayment.

EXAMPLE:

Mr. Brown was discharged to a Private Living Situation on January 2. His January SA payment after subtracting the PNA of $46 is $500. Mr. Brown would receive an SA payment for 5 calendar days (5 days allowed to report change to IMC) plus 10 working days (10 days timely notice period) after the day he left. Mr. Brown is eligible for SA payment through January 20 (Refer to calendar below). The amount of SA payment to be refunded is calculated below.

Number of days in month	31
Date 5/10 day rule ends	- 20
	11
SA Payment (Minus $46 PNA)	500
Number of Days in Month	÷ 31
Per Diem Rate	16.13
Number of Days of Recoupment	x 11
Amount of refund	177.42
Amount of refund (rounded)	$177.00

d. Ask the recipient to refund the recoupment voluntarily. Refer to SA-3300, Administration of Checks and Payments, for collection options.

e. If the recipient refuses to refund the recoupment, refer to SA-3410, Fraud.

Note: The 5/10 day rule does not apply for changes involving a move from the SA facility to a higher level of care or when the recipient dies. In those situations, the recipient is entitled to the payment for the entire month of change if he was in the facility on the first day of the month. The facility is required by licensure rules to refund to the recipient or his estate the portion of the payment after his discharge or death.

1. Payment Dispute Guidance

The IMC may be asked for guidance regarding the settlement of payment disputes among adult care homes and the a/r, when the a/r leaves the adult care home.

In all situations, settlement of payment to the SA facility is between the SA facility and the resident, as stipulated in the SA facility’s admission policy. Referrals should be made to the agency’s adult home specialist, who is familiar with all SA facility rules.

Adult Care Home Rules state:

10 NCAC 42C.2003 Settlement of cost of care

(b) If the resident, after giving written notice to the home of his/her intent to leave, moves out of the home before the 14 days have elapsed, the resident owes the administrator an amount equal to the cost of care for the 14 days. If the 14- day period for a resident receiving Special Assistance extends into another month and the resident moves early, the former home is entitled to the required payment before the new home receives any payment.

(d) (6) Exceptions to the 14-day notice requirement are:

1. Cases where returning to the home would jeopardize the health or safety of the resident or others in the home as certified by the resident’s physician or approved by the county department of social services;

2. In the case of the resident’s death.

B. Change in Level of Care

1. SA facility Basic (ambulation code B) recipient moves to a Special Care Unit (SCU) for Alzheimer’s (or related disorders).

a. Document the date recipient moved to the SCU.

b. Visit the facility to verify recipient is in a licensed SCU.

c. Verify the diagnosis on the current FL-2 is for Alzheimer’s or a related disorder.

d. Re-budget using the SCU rate beginning with the date of the move to the SCU.

See SA-3220.

e. Send aDSS-8110, Your Benefits Are Changing, Adequate notice for the increased payment amount.

2. An SA facility SCU recipient moves to the SA facility Basic (ambulation code B) area of the facility.

a. Document the date recipient moved to the SA facility basic section of the facility.

b. Re-budget using the SA facility Basic rate. See SA-3220.

c. Send aDSS-8110, Your Benefits Are Changing, Timely Notice to reduce the SA payment.

3. SA facility to Long-Term Care (Not expected to return within 30 days)

a. Document the date the agency received FL-2/MR-2, Level of Care Recommendation/Mental Retardation Services, in the record.

b. If a bed is available, send the DSS-8110, Your Benefits Are Changing (Adequate), to terminate SA benefits observing required time frames. Refer to SA-3330, Notices. If the recipient receives SSI, process DSS-8125, EIS Data Sheet, to transfer the case to Private Living Medicaid. The SSI recipient must still be evaluated for long-term care by appropriate IMC. If the recipient is Non-SSI, evaluate for Medicaid.

c. If the recipient or representative chooses not to accept the bed, the recipient is no longer eligible for SA.

d. If there is no bed available at the appropriate level of care, you may continue SA at the current rate until a bed is located. Review and document placement progress with the appropriate services staff each month until the recipient is placed using the DAAS-3005, Documentation Regarding Continuation of Special Assistance When the LOC Is Upgraded, But No Bed Is Available.

4. SA facility to Hospital Acute Care

a. If recipient returns to SA facility within 30 days make no changes.

b. If recipient is hospitalized for more than 30 days:

(1) Send the DSS-8110, Your Benefits Are Changing (Adequate), to terminate SA benefits observing required time frames. Refer to SA-3330, Notices.

(2) For SSI recipients, transfer to MA per instructions in EIS. Complete and send DMA-5049, Referral to Local Social Security Office, to SSA.

(3) For Non-SSI recipients, always evaluate for potential Medicaid eligibility and other program assistance.

NOTE: SAD applicants under age 21 (or age 22 who had their 21^st birthday while a patient in the state mental hospital) and all SAA applicants must be evaluated for Long-Term Care Medicaid.

5. SA facility to a Public Institution

When an SA recipient moves from an SA facility to a public institution and is not expected to return within 30 days, or is incarcerated, regardless of when they may return, take the following actions:

a. Verify and document change.

b. Send the DSS-8110, Your Benefits Are Changing (Adequate), to notify of termination observing required time frames. Refer to SA-3330, Notices.

c. For SSI recipients, transfer to MA per instructions in EIS. Complete and send DMA-5049, Referral to Local Social Security Office, to SSA.

d. For non-SSI recipients, always evaluate for potential Medicaid eligibility and other programs of assistance.

NOTE: If SAD a/r is under age 21 (or age 22, and had 21st birthday while a

patient in the state mental hospital), evaluate for long term care.

NOTE: If/When prior approval for nursing level of care is received, transfer to MA

in accordance with MA, LTC eligibility criteria.

C. Change in Resources

1. For SSI recipients, complete and send a DMA-5049, Referral to Local Social Security Office, to SSA. Do not take any action to terminate SA unless the change affects SSI eligibility.

2. For non-SSI recipients, verify and document change in resources according to instructions in SA-3200, Resources.

a. Record all verifications, including those items that are excluded from resource determination, on forms DAAS-8190-NS, Special Assistance Workbook for Non-SSI Recipients, and/or DMA-5030, Reserve History Sheet.

b. Process all changes in resources (i.e., real property, personal property and liquid assets) in accordance with SA-3200, Resources.

c. Contact the recipient and verify the resource the first day of the month following receipt.

d. If resources have been reduced to the allowable limit, verify reduction of resources. SA benefits continue.

e. If the value of the resources exceeds the resource allowance, send a timely DSS-8110, Your Benefits Are Changing (Timely) to propose termination. If the recipient provides documentation that resources are reduced to allowable limits within the timely notice period, SA benefits continue. If not, the SA payment terminates. Evaluate for potential Medicaid eligibility.

D. Change of Income

A change in income is defined as an acquired source of income, a change in rate or pay that will continue (not fluctuating income), or a termination of an existing source of income. Do not react to change until income is received.

1. For SSI recipients, send a DMA-5049, Referral to Local Social Security Office, to SSA. Do not take any action to change the SA payment unless the change affects SSI.

2. For non-SSI recipients, verify and document change in income according to instructions in SA-3210, Income.

a. To calculate the amount of new SA payment for increased or new income:

(1) Re-budget the payment effective the month the income is increased or the new source of income is received. Refer to SA-3220, Budgeting Principles.

(2) Send the DSS-8110, Your Benefits Are Changing (Timely), to terminate or reduce SA payment observing required time frames. The effective date of the revised payment is the month following expiration of the DSS-8110, Your Benefits Are Changing.

(3) If the SA payment terminates, evaluate eligibility for Medicaid.

EXAMPLE 1: Increased/New Source of Income:

On July 30, Mr. Brown reports that he will begin receiving his VA benefits effective August 1. IMC verified receipt of VA income on August 4 and rebudgeted a/r’s September and ongoing SA payments, including the new source of income. IMC keyed DSS-8125, EIS Data Sheet, generating an automated DSS-8110, Your Benefits Are Changing (Timely), on August 4 to notify recipient of change. Due to notice requirements, Mr. Brown’s VA benefits do not affect his August SA payment.

b. To calculate the amount of the new SA payment for terminated or decreased income:

(1) Re-budget the payment effective the month the income changed and ongoing months.

(2) Send the DSS-8110, Your Benefits Are Changing (Adequate), to notify recipient of change in payment. Key DSS-8125, EIS Data Sheet. Also send a manual DSS-8110, Your Benefits Are Changing (Adequate), to notify recipient of supplemental payments for months prior to the month of the effective date of the change in EIS. Issue these supplemental payments using the DMA-5022 Screen, Retroactive Eligibility Checks/ID Cards.

EXAMPLE 2: Decreased/Terminated Income:

On July 29 (after EIS pull-check deadline), Mr. Brown reported that his VA benefits decreased effective May 1. Rebudget a/r’s May, June, July August and ongoing payments using decreased income.

Send the manual DSS-8110, Your Benefits Are Changing (Adequate), to notify recipient of change in September payment. Key DSS-8125, EIS Data Sheet. Send a manual DSS-8110, Your Benefits Are Changing (Adequate), to notify recipient of supplemental payments for May, June, July and August.

c. To determine impact of overpayment and underpayment, refer to SA-3300, Administration of Checks and Payments.

E. Other Changes

1. Unable to Locate

If the recipient moves but leaves no forwarding address and you are unable to contact the representative:

a. For SSI recipients, transfer the case to MA per instructions in EIS. Complete and send DMA-5049, Referral to Local Social Security Office, to SSA.

b. For non-SSI recipients, send the DSS-8110, Your Benefits Are Changing (Timely), to terminate case observing required time frames. Refer to SA-3330, Notices.

2. SAD recipient reaches age 65

a. The Eligibility Information System (EIS) automatically transfers the case from SAD to SAA for both SSI and non-SSI recipients. This occurs at the end of the month in which the recipient turns age 65.

b. Assure that Medicaid begins paying Medicare premiums. Refer to MA-2410, Procedures for Medicare Buy-In. Evaluate for classification change to “Q” (Dual eligibility).

3. Disability

a. Verify and document when a recipient is determined no longer disabled.

b. Send the DSS-8110, Your Benefits Are Changing (Timely), to terminate Special Assistance observing required time lines. Refer to SA-3330, Notices.

(1) For SSI recipients, transfer to MA per instructions in EIS.

(2) For non-SSI recipients, terminate SA and evaluate for potential Medicaid eligibility and other programs of assistance.

4. Death

a. Verify and document date of death.

b. Send the DSS-8110, Your Benefits Are Changing (Adequate), to terminate Special Assistance.

(1) For SSI recipients, transfer to MA per instructions in EIS. Complete and send DMA-5049, Referral to Local Social Security Office, to SSA.

(2) For non-SSI recipients, terminate the case.

c. For any payments issued after death of the recipient, refer to SA-3300, Administration of Checks and Payments.

5. Change in State Residence

a. Document change of residence.

b. Send the DSS-8110, Your Benefits Are Changing (Timely), to terminate Special Assistance payment observing required time lines. Refer to SA-3330, Notices.

(1) For SSI recipients, transfer to MA per instructions in EIS. Complete and send DMA-5049, Referral to Local Social Security Office, to SSA.

(2) For non-SSI recipients, terminate the case.