0815.020.10 Participant Not Medically Certified – DSS Manuals

IM-120 November 18, 2021 ; IM-33 March 29, 2012

If Central Office Medical Review Unit (COMRU) determines that the applicant or participant is not medically certified for Nursing Facility (NF), Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID), or Mental Health Center (MHC) level of care, (LOC = NONE):

As a best practice, record a comment in the eligibility system to explain the individual’s ineligibility for vendor.

File a copy of the DA-124 Inquiry Report screen in the case record.

Enter the COMRU LOC determination on the Facility and Placement Information Details screen ( FACPLACE or FMJ4 ) DA-124A/B Level of Care field, and as a best practice, record a comment.

Complete the eligibility determination for MO HealthNet for the Aged, Blind, and Disabled (MHABD) Spend Down or Non-Spend Down.

Authorize the actions to approve or reject the MHABD request.

If COMRU determines that the applicant or participant is not medically certified for NF, ICF/IID or MHC level of care (LOC=SNC):

As a best practice, record a comment in the eligibility system to explain the individual’s ineligibility for vendor coverage.

File a copy of the DA-124 Inquiry Report screen in the case record.

Explore eligibility for an Supplemental Nursing Care (SNC) cash grant if the claimant is in or will be moving to a non–MO HealthNet certified bed by updating entries on the Facility and Placement Information Details screen ( FACPLACE or FMJ4 ) to facility type CGZ and type of bed SNF . Refer to the Facility and Placement Information Details user guide. Determine eligibility for SNC from the date of the request for MHABD vendor. Determine if the individual is qualified for SNC, using 0600.000.00 Supplemental Nursing Care (SNC) .

If ineligible for a SNC cash grant, complete the eligibility determination for MHABD Spend Down or Non-Spend Down.

Authorize the actions to approve or reject the MHABD request. NOTE: Always review the Budget Summary screen prior to authorizing a case action in the eligibility system. View the Expense Summary Detail screen to ensure all countable income and expenses are included in the budget.