Purpose: This section will assist in determining whether an individual is eligible for Nursing Home/Swing Bed services and in determining the cost of care for these services.

Current Policy Effective Date: June 1, 2022

Date Last Reviewed: April 29, 2022

Previous Policy : March 1, 2022

POL 1001A: DETERMINING ELIGIBILITY FOR NURSING HOME/SWING BED 1. Applicants Must Meet Basic Eligibility Factors Refer to Section M600 for a description of all basic eligibility factors. 2 Applicants Must Meet Medical Necessity Requirement Applicants must meet medical necessity. Medical necessity is verified, at initial application or when the client is moving to the Nursing Home program from another coverage group, through the LT101 assessment if the client is 19 years of age or older or the LT104 assessment if the client is younger than 19 years of age, on the Provider Web Portal and will show as eligible on the placement summary. Require a new LT101 or LT104, when the referral date on the assessment is over 365 days. Once medical necessity is verified and the referral date on the assessment is within 365 days, authorize benefits beginning with the first month of eligibility.

3. Applicants Must Be Aged, Blind Or Disabled

Applicants must meet one of the following factors:

Aged – 65 or older.

Blind – legally blind based on Social Security standards.

Disabled – person who receives disability benefits from SSA or is determined disabled by WDH.

4. Applicants Must Meet 30-Day Requirement

Applicants must meet a 30-day requirement by any of the following:

Remain in an institution for 30 consecutive days. Not completing the 30-day requirement due to death. Verified as SSI eligible. Receive Home and Community Based Waiver Services immediately prior to entering the nursing home.

5. SSI Eligibles Do Not Need To Submit Application

If client becomes ineligible for SSI, an application will be required to determine continued eligibility under another coverage group.

6. Applicants Must Meet Income Requirements

Require the countable income to be within the maximum income standard per month. Refer to Medicaid Table 1A to see income standards. Refer to Section M901 to determine if income is countable. Provide an Income Trust Packet when the countable income is above the maximum income standard.

7. Applicants Must Meet Resource Requirements

Require the countable resources to be within the maximum resource limit. Refer to Medicaid Table 7 to see resource standards. Refer to Section M801 to determine if resource is countable.

8. Some Services Withheld For Resource Transfers

Resources cannot be transferred for less than fair market value during the look-back period, prior to application or when a client is receiving benefits.

If clients transfer resources for less than fair market value but meet all other eligibility factors, a penalty period must be imposed. The following will occur during the penalty period:

Payment for nursing home facility services must be withheld.

Other Medicaid services must be authorized.

Clients must receive notification that they are Medicaid eligible even though nursing facility services will not be covered for the penalty period.

Refer to Section M803 to determine if a resource transfer is exempt and Section M804 for information on related penalties.

9. Benefits Begin First Month Of Eligibility

Once applicants meet the 30-day requirement of institutionalization, benefits must be authorized beginning with the first month of eligibility.

10. Applicants May Receive Retroactive Medicaid

Applicants may receive retroactive Medicaid benefits if they incurred medical bills during any of the three months prior to application.

Both approved and denied applicants must be reviewed. Reviewer must verify and determine eligibility separately for each retroactive month to determine whether the case would have been eligible if an application had been made. Medical bills may be paid for this period when eligible.

11. Clients Pay Patient Contribution

Client is required to pay a contribution toward the cost of care.

Require the client to pay toward the cost of care when a partial month penalty is imposed due to a transfer of a resource.

Refer to Section M906 for details on calculating the patient contribution.

12. Clients May Pay Prorated Amount

Prorate the patient contribution when the client does not reside in a nursing home for a full month or Medicare pays for the cost of care. Refer to Section M906 for details on calculating the patient contribution.

13. Clients May Not Pay Patient Contribution First Month

Nursing home clients who are Medicaid eligible when they enter the facility, do not pay a patient contribution during their first month of eligibility. Clients must pay a patient contribution the first full month following 30 days of nursing home residency.

14. Clients Pay No Patient Contribution When Transitioning To HCBS

15. Clients In Nursing Home May Continue Receiving Hospice

Clients who elect Hospice while in a nursing home should remain on the Nursing Home program and continue to pay a patient contribution to the nursing home. Refer to M1001C for Hospice specific information.

If the client elects Hospice and is authorized for the Hospice program prior to entering the nursing home, the client will not have a patient contribution.

16. Applicants May Have Eligibility For 12 Continuous Months

The eligibility continues for 12 months from the effective date of eligibility, or for 12 months from the last periodic review, for children under the age of 19.

17. Clients must be reviewed

Clients must be periodically reviewed every 12 months to determine continued eligibility. Refer to Section M1403 for information on reviewing eligibility.

A review is not required for SSI clients.

Clients must be reviewed for other Medicaid program eligibility before closing cases

18. Clients May Lose Benefits

The case will close when any of the following occur:

Client leaves nursing home.

Client does not complete review.

Client dies.

Client determined no longer eligible.