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UPDATED: JANUARY 2011

520

OTHER ELIGIBILITY REQUIREMENTS

DISTRICT OF FISCAL RESPONSIBILITY (DFR)

Medical Facility Rule

The local district of legal residence continues to be responsible for providing Medicaid to a person who has entered a medical facility in another district if the person is in need of Medicaid upon admission to the facility, or becomes in need during the inpatient stay, or upon discharge from the facility. This responsibility continues indefinitely until there is a break in the recipient’s need for Medicaid.

When applying these provisions to a Title XIX facility operated or certified by OMH or OPWDD, regardless of where the facility is located, the district of legal residence (“from district”) remains responsible until there is a “break in need”.

A “break in need” is defined as one calendar month without financial eligibility. As long as an individual remains financially eligible for Medicaid, there is no break in need. If the individual has excess income and submits paid or incurred expenses totaling the amount of excess or pays the excess directly to the district, there is no break in need. If in any month, the SSI-related individual becomes resource ineligible and is unable to spend down the excess resources or does not meet an excess income liability, there is a break in need. When a break in need occurs, the district of fiscal responsibility may close the case with adequate and timely notice.

District Placement Rule

When the A/R's district of residence arranges or participates actively in arranging for care in another local district, that district is assuming responsibility for the continuing care of that A/R, regardless of the type of facility the person enters. The A/R’s district of legal residence continues to be, or becomes responsible for providing Medicaid when: a district (either the local district of legal residence or any other district) was involved in placing the eligible person into a formal residential care setting in another district. District involvement in a placement includes both direct and indirect involvement by any county agency or official governmental entity of the county including courts, mental health departments, probation departments, etc.

(MRG)