*** The Health Care Programs Manual (HCPM) has been replaced by the Minnesota Health Care Programs Eligibility Policy Manual (EPM) as of June 1, 2016. Please refer to the EPM for current health care program policy information. ***
Effective: December 1, 2011 |
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23.30 - Eligibility Determination and System Coding for MA Payment of LTC Services |
Archived: June 1, 2016 |
There are specific eligibility requirements for Medical Assistance (MA) payment of long-term care (LTC) services that do not apply to eligibility for basic MA. As a result, a person may be eligible for basic MA but ineligible for MA payment of LTC services. A person, including a current MA applicant or enrollee, must meet all eligibility requirements for MA payment of LTC services before MA can pay for LTC services.
The Medicaid Management Information System (MMIS) automatically enters a U code in the LTC Ineligible Information section of the RLVA screen with a begin date matching the begin date of eligibility for basic MA when major program MA, EH, NM or RM is opened on the RELG screen. The U code indicates eligibility for MA payment of LTC services is undetermined.
A worker indicates the results of the eligibility determination for MA payment of LTC services in the LTC Ineligible Information section of the RLVA screen in MMIS. Only update the LTC Ineligible Information section of the RLVA screen after an eligibility determination for MA payment of LTC services has been completed.
The RLVA screen in MMIS must accurately reflect an MA enrollee’s eligibility status for payment of LTC services so that:
l providers and health plans know whether or not an MA enrollee is eligible for MA payment of LTC services.
l claims for LTC services are only paid when an enrollee is eligible for MA payment of LTC services.
l lead agency case managers can open a home and community-based waiver span in the screening subsystem of MMIS.
Providers are aware of the U code. As a result, they may contact workers to request the removal of the U code so that they can receive payment for an LTC service claim. Do not remove or end date the U code unless an eligibility determination for MA payment of LTC services has been made.
Closing MA Payment of LTC Services.
Enrollee No Longer Resides in an LTCF.
Enrollee No Longer Eligible for a Waiver Program.
Enrollee is No Longer Eligible for MA Payment of LTC Services.
The LTC Ineligible Information section of the RLVA screen in MMIS has seven codes that indicate ineligibility for MA payment of LTC services. The codes represent different reasons why a person can be ineligible for MA payment of LTC services. A person is ineligible for MA payment of LTC services until a worker determines the person is eligible.
The LTC Ineligible Codes on RLVA are:
l U code - Undetermined. The U code indicates eligibility for MA payment of LTC services is undetermined.
l P code - Managed Care. The P code indicates when a managed care organization is responsible to pay for LTC services for an MA enrollee who resides in a Long-Term Care Facility (LTCF). The P code is not a factor in the eligibility determination for MA payment of LTC services. Updates to this ineligible code are completed by DHS managed care staff.
l L code - Level of Care. Use an L code on the LTC Ineligible Information section of RLVA to indicate if an MA applicant or enrollee does not meet the level of care requirements.
l N code - Never Screened. Use an N code on the LTC Ineligible Information section of RLVA if an MA applicant or enrollee did not cooperate in determining his or her level of care requirements.
l H code - Home Equity. Use an H code on the LTC Ineligible Information section of RLVA to indicate if an MA applicant or enrollee does not meet the home equity requirement.
l A code - Naming DHS a Preferred Remainder Beneficiary of an Annuity. Use an A code on the LTC Ineligible Information section of RLVA if an MA applicant or enrollee is ineligible for MA payment of LTC services because he or she refuses to name DHS a preferred remainder beneficiary.
l I code - Uncompensated Transfer. Use an I code on the LTC Ineligible Information section of RLVA to indicate if an applicant or enrollee is ineligible for MA payment of LTC services because of a transfer penalty.
When a person has been determined eligible for MA payment of LTC services, a worker must determine the date MA payment of LTC services may begin. Once the begin date is determined, a worker must enter an end date for all U, L, N, H, A or I LTC ineligible codes that are open for the time period in which the person is eligible for MA payment of LTC services. The LTC ineligible codes must have an end date one day prior to the begin date for MA payment of LTC services.
Example:
Willard applies for MA on April 18 requesting retroactive coverage to January 1. He has resided in an LTCF since January 6. On May 5 his worker determines Willard is eligible for MA beginning January 1 and that he meets all eligibility requirements for MA payment of LTC services beginning in January.
Action:
Willard is eligible for MA payment of LTC services effective January 6 because it is the first date in which he meets the eligibility requirements for MA payment of LTC services and resides in an LTCF. Take the following steps:
1. Enter MA eligibility on RELG beginning January 1; this populates a U code in the LTC Ineligible Information section of RLVA with a begin date of January 1.
2. Enter an end date of January 5 on the U span on RLVA. There is no eligibility for MA payment of LTC services from January 1 through January 5.
3. Notify Willard that he is eligible for MA payment of LTC services beginning January 6. Add worker comments to the MAXIS system notice. If there is not enough space for worker comments, send the Notice of Action for Medical Assistance (MA) Payment of Long-Term Care Services (DHS-4915) and retain a copy in the case file.
Closing MA Payment of LTC Services
If an enrollee is currently receiving MA payment of LTC services, but is no longer eligible, determine the appropriate end date for MA payment of LTC services in order to correctly code the LTC Ineligible Information section of the RLVA screen. The end date can vary based on the reason why the enrollee is not eligible for MA payment of LTC services. Entry of the LTC ineligible codes begins one day after eligibility for MA payment of LTC services ends.
Enrollee No Longer Resides in an LTCF
An enrollee who resides in an LTCF stops receiving LTC services when he or she no longer resides in an LTCF. Therefore, there are no LTC services for MA to pay. The last day for MA payment of LTC services is the day the person leaves the LTCF. A ten-day notice is not required to stop MA payment of LTC services in this situation. However, ten-day notice is generally required to close basic MA if leaving the LTCF results in ineligibility for basic MA
Enrollee No Longer Eligible for a Waiver Program
The lead agency case manager must provide notice to a person if the person is no longer eligible for a home and community-based waiver program. The advance notice requirements that a lead agency case manager must follow are different from those for MA. The end date for MA payment of LTC services for a waiver enrollee is the date the lead agency case manager states that the waiver will or has ended. The lead agency case manager communicates this information to the worker via the Lead Agency Case Manager/Worker Communication Form (DHS-5181). The Notice of Action Home and Community-Based Waiver Services and AC (DHS-2828), provided by the lead agency case manager, contains the mandatory information an agency must provide when the agency takes adverse action. Because the lead agency case manager has already provided a notice to the person, do not send another notice regarding eligibility for MA payment of LTC services. Begin a U span for the day after the last day of waiver service eligibility per the DHS-5181.
Enrollee is No Longer Eligible for MA Payment of LTC Services
A 10-day notice is required in order to close MA payment of LTC services when a person is no longer eligible for MA payment of LTC services. The effective date of the closure is the first calendar day of a month in which a 10-day notice can be provided.