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West Virginia Income Maintenance Manual Chapter 24

West Virginia Income Maintenance Manual Page 28 Chapter 24 Long Term Care

• Co-insurance payments while the individual is Medicaid eligible and has Medicare or private health insurance; • Charges for an ambulance or transportation which is medically necessary for an individual in a nursing facility who is Medicaid and/or Medicare eligible or has private insurance; • Charges incurred during temporary periods of Medicaid ineligibility when the reason is failure to complete a redetermination and the assistance group (AG) is subsequently reopened with no break in eligibility periods; • Nursing facility charges when the reason for Medicaid ineligibility is the facility’s failure to obtain an approved preadmission screening (PAS); and • Charges for bed hold days. 24.7.4 FIRST AND LAST MONTH CALCULATIONS During the first month and last month in which Medicaid participates in the cost of care, the Worker must prorate the client’s contribution to his cost of care when he does not spend the full calendar month in the facility. This policy applies only to the first and last months of nursing facility residence when Medicaid participates in the payment. It is not used when the client leaves the facility for other medical treatment, for family visits, etc. During all other months, the client must pay his full contribution and be reimbursed by the facility if an overpayment occurs. This proration is accomplished as follows: • Determine the client’s total monthly cost contribution amount as for any other nursing facility resident who expects to remain in the facility a full month. • Divide the client’s total monthly cost contribution by the actual number of days in the calendar month. This becomes the client’s daily contribution rate, which is used for this purpose only. • Determine the number of days the client resided or expects to reside in the facility in the calendar month. When the contribution is prorated for the last month of nursing facility residence, only days during which the client resides in the facility are calculated. Days during which the client does not reside in the facility, including bed-hold days, are not considered. Multiply the number of days by the daily contribution rate. • The result is the client’s total cost contribution for the partial month. After all computations have been completed, any cents calculated as part of the result are dropped.