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North Carolina Department of Health and Human Services AGED, BLIND AND DISABLED MEDICAID MANUAL
MA-1100 AGED, BLIND AND DISABLED
SSI MEDICAID – COUNTY DSS RESPONSIBILITY
10 REISSUED 10/01/05 – CHANGE NO. 28-05
IV. COUNTY DSS RESPONSIBILITY WHEN AN SSI RECIPIENT ENTERS LONG TERM CARE (LTC)
When an ongoing SSI recipient enters long term care (or psychiatric residential treatment facility (PRTF) if under 21), SSA continues to determine Medicaid eligibility. However, the recipient or his representative must contact the county dss and request payment for nursing home cost of care. Payment for nursing home cost of care is not an automatic benefit for SSI Medicaid recipients. In order to establish eligibility for cost of care, the county dss must consider the following:
• County of residence • Patient Monthly Liability (PML) • Level of Care (FL-2/MR-2) – Not applicable to PRTF (Refer to MA-2270, Long Term Care Need And Budgeting) • Transfer of Resources – Not applicable to PRTF as transfer of resources sanctions apply only to nursing facility expenses, CAP waiver program, and in-home health services and supplies. See MA-2240, Transfer of Resources, for the definition of in-home health services and supplies. • Community Spouse and dependents income allowance • Community Spouse Resource Protection
Inpatient treatment in a psychiatric residential treatment facility (PRTF) is a covered service for individuals under 21. The claims are paid the same way as for a nursing facility. Admission to a PRTF is treated as an admission to a nursing facility for budgeting purposes.
Take the following steps to determine if an ongoing SSI Medicaid recipient is eligible for payment of cost of care:
A. Establish County of Residence
Refer to MA-2221, County Residence.
1. If the recipient has established residence in another county, or the SDX shows the incorrect county of residence, refer the a/r to the correct county to request cost of care.
2. If the recipient last lived in pla outside of North Carolina, the county of residence is the county where the a/r resides in the nursing facility.
3. If there is a conflict in county residency, refer to MA-2221, County Residence.