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a. The a/b goes from pla (including adult care home or hospital) to a nursing facility, or

b. Increases or decreases the amount of the PML, or

c. Changes the case address, or

d. Enters a new facility code, or

e. Changes the facility code.

2. The caseworker completes a manual DHB-5016, Notification of Eligibility for Medicaid/Amount and Effective Date of Patient's Liability when: a. The a/b is in 2 or more facilities in a month and each facility is due a portion of the pml. (See IX.D., below for procedures to split the PML.) Different levels of care within a hospital such as acute care and swing bed are considered two separate facilities for claims processing purposes. The caseworker must send a manual DHB- 5016 to each facility to notify it of its share of the PML, OR

b. There is a deductible balance and a PML in the same month. This situation occurs when the a/b moves directly from acute care in a hospital to a swing bed within the same facility or to a separate nursing facility. The caseworker must send a manual DHB-5016 to the facility to notify it of the PML. This applies even when the PML is "$0."

3. There are specific situations in which a DHB-5016 is never sent. These occur when a case is budgeted according to PLA procedures and is authorized only for other Medicaid covered services. These situations are:

a. There is no approved FL-2 when the FL-2 is required; or

b. The a/b is under a transfer of asset sanction; or

c. The facility is not certified yet.

C. Procedures When PML Changes 1. Beneficiary notice requirements

a. If PML amount increases, timely notice is required.

b. If PML decreases, adequate notice is required. 2. Special Situations

a. If one of the following exceptions applies, notify DHB, using DHB- 5164, Change to PML Request.

Docusign Envelope ID: 950E9248-29CC-8930-81BC-BCEC667EB493