8172 Eligibility for Persons in Medicaid - Approved Institutions - Financial eligibility shall be determined by first computing a monthly patient liability. The patient liability is a monthly amount the individual is responsible for paying toward his or her care cost each month, if the provisions of 8172.2 (1) are met. The patient liability is the amount of income in excess of the LTC standard. As noted in 8150, all exempt and nonexempt income is considered. Where applicable, the liability should take into account the amount of any income allocation in accordance with the provisions of 8143 (4) or 8144.2. The patient liability is further reduced by allowable medical expenses.
8172.1 Allowable Medical Expenses - To be allowed against the patient liability, expenses must be incurred in the current eligibility base or incurred outside of the current eligibility base and the individual was legally obligated to pay the expense on the first day of the base and such expense has not been previously applied to another patient liability, client obligation or spenddown in which the spenddown was ultimately satisfied. This includes instances when the individual has taken out a loan to pay the expense or charged the balance on a credit card. Medical bills transferred to a collection agency for repayment are considered the responsibility of the individual.
Allowable expenses can be applied to a future month's patient liability when it is not possible to account for the expenses in the month they are incurred because of the use of a one-month base period.
Medical Expense Limitations -
An expense must be the responsibility
of the consumer to be allowable. The portion of any expense assumed
by a third party, whether legally liable or not, negates the individual's
responsibility to pay and therefore, are not allowable, except for
expenses assumed by a third party as per 7532.3.
This includes the portion of any allowable medical expense paid by
Medicare or other health insurance. The portion not covered by insurance
(such as the copayment or deductible) or not assumed by another third
party is allowable. Prescription drug expenses which are not covered
under the Medicare Part D plan are allowable if an exception to coverage
has been rejected by the plan. Also see item (2)(b) below regarding
expenses which are the responsibility of the nursing facility. Medical
bills transferred to a collection agency for repayment are considered
the responsibility of the individual.
For due and owing expenses the following
rules apply:
For unpaid expenses, the total
amount due and owing on the first day of the base periods is allowable,
except for the portion used in a previous base or obligated by
a third party. Bills used against a prior spenddown may be allowed
in a subsequent base period only if the prior spenddown was not
met. Only the portion still due and owing on the first day of
the current base period is allowable.
For expenses paid with a loan
or credit card, only the unpaid portion of the loan or credit
card balance attributable to the original medical expense is allowable.
This is determined by subtracting all payments made on the loan
or card balance from the original expense amount less any third
party payments. Verification on the initial medical expense as
well as payments made are required.
Allowable
Expenses - Services must be verified to be allowed. The
following are considered allowable services or items:
The pro rata portion of medical insurance premiums for the number of months covered in the eligibility base period, regardless of the actual date of payment, past or future are allowable. This includes all types of health insurance plans, including limited coverage plans providing for single disease or specialized coverages, such as long term care, cancer, prescription drug or hospitalization plans. However, premiums for some hospital indemnity plans which pay a flat rate (such as a per day or per occurrence payment) are not allowable unless payment is dependent upon the insured receiving certain services or treatments. Each policy must be reviewed to determine if the premium is allowable.
Medicare premiums not covered by buy-in are also
allowable. See policy memo 99-10-04
for guidelines on applying premiums prior to accretion to buy-in.
Premiums which are subject to buy-in are not allowable even if
the client pays them (or they are withheld) prior to completion
of the buy-in process as such amounts are subject to reimbursement
to the Medicare beneficiary. Additional costs paid for Medicare
Advantage policies are not reimbursed through buy-in but are an
allowable medical insurance premium. Additional premiums paid
by the beneficiary for Part D coverage are allowable if not subject
to reimbursement by the Subsidy. This includes surcharges for
late enrollment and charges to upgrade the plan above the basic
level.
If medically necessary, all
expenses for medical services incurred by the individual beginning
with the first month of eligibility, are allowable. See Appendix
item #P-1 for a list of medically necessary services and items.
For nursing facility residents, items and services
which are the responsibility of the facility to provide are not
allowable. The NF is required to ensure that residents receive
all medically necessary items, including those routine services
and supplies which facilities are required to make reasonable
accommodations to supply to their residents. Products which can
be purchased over the counter or are regularly available without
a prescription are the responsibility of the NF. Providers are
expected to stock a variety of product choices for each major
type of routine supply (at least two). If a resident elects to
use a product other than the similar products the NF stocks, the
resident will assume responsibility for the costs of the item,
but it is not allowable against the patient liability. A complete
list of services which are considered the responsibility of the
facility is found at in the Adult Care Home Provider Manual, Section
8400. KDOA is responsible for maintaining this list.
8172.2 Application of Patient Liability - If
the resulting monthly patient liability is less than the monthly Medicaid
rate for the facility, payment can be made toward the cost of care. The
monthly rate is determined by multiplying the Medicaid daily rate of the
facility by 31. The individual is eligible for other medical benefits
under the Medicaid benefit plan.
If the resulting monthly patient liability exceeds the monthly Medicaid
rate for the facility, no payment would be made towards the cost of care
unless the obligation can be reduced below the SRS rate for any month.
(See 8131.) To determine eligibility
for other medical benefits, a monthly spenddown must be computed in accordance
with the independent living rules in 7530
and subsections including consideration of only nonexempt income, use
of the independent living PIL, and the income disregards of 7240.
The spousal impoverishment income provisions of 8144.2
and the allocation of income provisions of 8143
(4) would not be applicable but the separate income rules of 8143
would apply.
If the resulting spenddown amount
(without deduction of other medical expenses) is less than or equal
to the monthly Medicaid rate for the facility, the individual is eligible.
Even though Medicaid is not participating in payment, the facility
is limited to charging the consumer the Medicaid daily rate. This
determination is completed and documented off the system (see Appendix
Item #W-4). It is important that the case continue to appear as a
nursing facility case, including computation of the patient liability
and indicating cost of care exceeds liability on the SPEN screen in
KAECSES. LOTC must be completed with the full patient liability.
If the spenddown amount is greater
than the SRS approved charges, there is no eligibility initially.
The individual is subject to private care rates.
The case would then be processed using independent living standards under the Medically Needy program, see 7532. The spousal impoverishment income provisions of 8144.2 and the allocation provisions of 8143 (4) are not applicable. A six month base is applicable. If the individual meets the spenddown, he or she is eligible for medical coverage, but there is no reimbursement for NF services. The estimated cost of the individual's NF care up to the private care rate would be applied to spenddown (see 7532.2 (2)). It is necessary to identify the individual as an NF resident in the MMIS. This is accomplished by completing the LOTC with a living arrangement code of "NS" (no state payment), a patient liability of $0, a provider number of "0", and a level of care code of "NA".
8172.3 Retroactive Patient Liability Changes - A change to an established patient liability must be made prior to the first day of the base period, except as noted below, as timely and adequate notice requirements permit (see 1430 and subsections). Generally, the patient liability is finalized beginning the first day of the month the liability is effective, and no additional changes are to be made to the amount. However, the following situations must be acted upon and a liability change may result. Proper notification is issued to both the recipient and the facility:
A change in living arrangement requires
a budgeting change, resulting in a reduced liability for the current
calendar month or a past month. These situations generally involve
an individual moving from a LTC/NF arrangement to Medically Needy,
HCBS or Working Healthy. The resulting change is acted upon beginning
the month the new arrangement begins or a following month, depending
on the age of the individual and spousal impoverishment.
An agency error has resulted in an overstated liability for the current calendar month or a past month. These include situations where an error was made by the agency, which resulted in an overstated liability for one or more of these months. Also included are situations in which the intended liability did not transmit to the MMIS appropriately, but adequate and timely (if applicable) notice requirements were met at the time of the change. Understated liabilities may be changed only if the consumer and facility were timely notified of the liability change and the new liability did not transmit to the MMIS appropriately. Supervisory approval is needed to authorize the retroactive liability change in these situations.