1. Customer Not Entitled to Medicare Benefits
    1. In Facility for Whole Month
    2. In Facility for Less Than Whole Month
    3. Temporary Absence for Hospitalization or Home Visit
    4. Discharge to Community
    5. Death of Resident
    6. Transfer Between Nursing Homes
    7. Transfer from DHS Facility to Private NH or SLF
    8. Transfer from SLF
    9. Transfer from NH to SLF
  2. Customer Entitled to Medicare Benefits
    1. Full Medicare Days Over Maximum Allowed
    2. Medicare Coinsurance Days Over Maximum Allowed
    3. Handling Income

Customer Not Entitled to Medicare Benefits

  1. (Facility) Collects funds taken as credit by HFS. A split bill form is not needed for Revised textNH or SLF services.
  2. (FCRC) Decide the credit amount a facility is to apply to cost of care for each customer. See PM 23-08-00 and WAG 23-08-00 about third party (TPL) payments for long term care.
  3. (FCRC) For admits, enter credit amount New textin the MMIS LTC subsystem.

    Revised textOptional: Enter credit amount on Long Term Care Authorization (Form 2299), in Section C, Recipient Available Income and Revised textResources.

  4. (FCRC) Report an income change Revised textfrom the Revised textNursing Home/Supportive Living Facility Resource Calculation (Form 2500) by entering credit amount New textin the LTC subsystem. The credit is also shown in Item 80 of Form 552.

    Revised textOptional: Report the income change on Long Term Care Authorization (Form 2299), in Section C, Recipient Available Income and Revised textResources.

  5. (FCRC) Allow Revised textNH residents $30 per month for personal needs. For customers with income, the first $30 is used for the personal needs allowance.
    1. For SLF residents who are not sharing a room, allow the amount of the current SSI rate for a single person for personal needs. For SLF residents who are sharing a room, allow 1/2 the amount of the current SSI rate for a couple for personal needs.
  6. (FCRC) Allow additional income exemptions or deductions, when applicable, in addition to the amount permitted for personal needs. See PM 15-04-04-e and WAG 15-04-04-e for veterans or surviving spouses residing in Revised textnursing homes.
  7. (FCRC) Use the Revised textNH Standard ($30) to figure available income when a customer:
    • is in a facility for the whole month (See PM 15-04-04-e and WAG 15-04-04-e for veterans or surviving spouses residing in Revised textnursing homes.); or
    • enters an Revised textNH from a hospital and had lived in an Revised textNH, SLF, or DHS facility before the hospitalization.
  8. (FCRC) Use the SLF Standard to figure available income when a customer:
    • is in an SLF for the whole month; or
    • enters an SLF from a hospital and had lived in an SLF, Revised textNH, or DHS facility before the hospitalization.
  9. (FCRC) Use the Community Standard to figure available income if a customer:
    • lives in the community for part of the month; or
    • enters the facility from a hospital and had lived in the community before the hospitalization.
  10. (FCRC) Apply Revised textNH and SLF service charges during the month of discharge to the community spenddown, if any.
  11. (FCRC) Figure countable income to be credited toward the cost of care based on the resident's status.

In Facility for Whole Month

Apply all nonexempt income and excess Revised textresources for a calendar month to the cost of care for that month's billing period, if the customer is in the facility for the whole month. Use the appropriate Revised textNH or SLF Standard.

Example: On 07/01, Ms. Jackson is admitted to an Revised textNH from the community. She has a monthly income of $450. She has no dependents in the community and no medical insurance.

Use the Revised textNH Standard to figure available income to apply toward the cost of care beginning with the July billing period (07/01 to 07/31). Budget income received in July toward the July billing period.

In Facility for Less Than Whole Month

Apply countable income and nonexempt Revised textresources following Revised textNH and SLF policy (see PM 15-06-02 and PM 15-06-03) for a customer who enters a facility from the community after the first of the month.

Temporary Absence for Hospitalization or Home Visit

  1. (FCRC) Use the appropriate Revised textNH or SLF Standard when a customer leaves the facility for a home visit or hospitalization if they will be returning to the facility.
  2. (FCRC) Credit income received during the month (up to the amount of incurred charges) toward the cost of care for the billing days the customer is in the facility.

Discharge to Community

  1. (FCRC) Use the community standard for any part of a month when a customer is discharged to:
    • the community; or
    • a hospital and will be discharged to the community from there.
  • Example: On 11/15, Ms. A is discharged to the community. The cost of care in the facility at the private pay rate is $60 per day. She did not incur any other medical expenses for November before discharge from the facility. She has no spouse at home.
  • Use the community standard to figure countable income:
  • $800
    -25 disregard
    -283 standard
    $492 spenddown amount
  • The credit amount for the November billing period (11/01 to 11/30) is the amount of charges for 11/01 to 11/14 used to meet the November spenddown amount ($492). November spenddown is met 11/01.
  • Enter the discharge date of 11/15 New textin the MMIS LTC subsystem.
  • Revised textOptional: The discharge may be recorded in Section A of Form 2449.
  • Enter 11/01 and $492 in New textthe MMIS LTC subsystem.
  • Revised textOptional: 11/01 and $492 may be entered Section C of Form 2449.

Death of Resident

  1. (FCRC) Use the appropriate Revised textNH or SLF Standard to figure countable income when a resident dies.
  2. (FCRC) Do not budget income received after the date of death.

    Example: Mr. A died on 03/02. His only source of income was Social Security. The Social Security check was received 03/03. Nonexempt Revised textresources are less than the Revised textresource limits.

    Do not budget the Social Security check received 03/03 for March. There is no credit amount for March.

    Revised textEnter 03/01 with a zero credit amount and 03/02 date of death in the MMIS LTC subsystem.

    Revised textOptional: 03/01 with zero credit amount and 03/02 date of death/discharge may be entered in Section C and Section A of Form 2449.   

  3. (FCRC) Budget income received on or before the date of death toward the cost of care.
  4. (FCRC) Budget income received before the date of death but not endorsed, as available toward the cost of care.
  • Example: Mr. A resided in an Revised textNH. He died on 07/10. His monthly income of $500 was received on 07/03 but his check was not endorsed at the time of his death. Use the Revised textNH Standard to figure available income:
  • $500
    - 30 standard
    $470 available income
  • Apply July's income toward the cost of care for the July billing period. Enter 07/10 New textin the MMIS LTC subsystem.
  • Revised textOptional: 07/10 may be entered in Section A of Form 2449.

Transfer Between Nursing Homes

  1. (FCRC) Apply the Revised textNH credit for the month of transfer toward charges at the first facility and apply any balance as the Revised textNH credit for charges at the 2nd facility, when a customer transfers:
    • between private facilities; or
    • between DHS facilities; or
    • from a private facility to a DHS facility.
  • Example: On 12/07, Ms. B transfers to a different Revised textNH. The Revised textNH credit for December is $770 and exceeds the cost of care at the first facility. HFS makes no payment for December.
  • Deduct the cost of care at the first facility for 12/01 to 12/06 ($470) from the Revised textNH credit for December. Apply the remainder ($300) as the Revised textNH credit for the cost of care at the 2nd facility for 12/07 through 12/31.
  • $770 Revised textNH credit
    -470 cost of care at first facility
    $300 remainder

Transfer from DHS Facility to Private NH or SLF

  1. Apply the credit for the month of transfer toward charges at the DHS facility. There is no credit amount figured for the 2nd facility for the month of transfer.
  2. Figure the credit amount, for the 2nd facility, starting with the month following the transfer.
  • Example: On 05/20, Mr. Smith transfers from a DHS facility. The credit for May is $700.
  • Apply the credit for May against the cost of care at the DHS facility. There is no credit amount figured for May at the 2nd facility.
  • Figure the credit amount for the 2nd facility beginning in June.

Transfer from SLF

  1. When a person transfers from an SLF to an Revised textNH or SLF, apply the SLF credit for the month of transfer toward charges at the first facility and apply any balance as the Revised textNH/SLF credit toward charges at the 2nd facility.
  • Example: On 10/05, Ms. C transfers from an SLF to an Revised textNH. The SLF credit for October is $300.
  • Deduct the cost of care at the SLF for the period 10/01 to 10/04 ($200) from the SLF credit for October. Apply the remainder as the Revised textNH credit for the cost of care at the Revised textNH for the period 10/05 through 10/31.
  • $300 SLF credit
    -200 cost of SLF services
    $100 remainder

Transfer from NH to SLF

  1. When a person transfers from an Revised textNH to an SLF, do not apply the $30 Revised textNH standard for the month of transfer. Apply a revised Revised textNH standard. Determine the revised Revised textNH standard for the month of transfer as follows:
    • subtract $90 from the SLF standard;
    • divide the remaining amount by 30;
    • multiply this amount by the days at the SLF; and
    • add $90.
  • (SLF standard - $90) ÷ (30) × (days at SLF) + ($90)
  • Refigure the Revised textNH credit for the month of transfer using the revised Revised textNH standard. Apply the Revised textNH credit toward charges at the Revised textNH and apply any balance as the SLF credit toward the charges at the SLF.
  • Example: On 11/04, Mr. D transfers from an Revised textNH to an SLF. Mr. D is not sharing a room at the SLF. November income is $800.
  • The revised Revised textNH standard for November is $459.09 ($500 - $90 = $410 ÷ 30 = 13.67 × 27 = $369.09 + $90 = $459.09). The November Revised textNH credit is $340.91 ($800 - $459.09 = $340.91).
  • Deduct the cost of care at the Revised textNH for the period 11/01 to 11/03 ($225) from the Revised textNH credit for November. Apply the remainder (Revised text$115.91) as the SLF credit toward the cost of care at the SLF for the period 11/04 through 11/30.
  • $340.91 Revised textNH credit
    -225.00 cost of Revised textNH services
    Revised text$115.91 remainder

Customer Entitled to Medicare Benefits

  1. (Facility) Notifies the FCRC using Revised textthe LTC EDI system (via MEDI or REV) when a person enrolled in Medicare is admitted to a Medicare certified bed for SNF services.
  2. (Facility) Notifies the FCRC using Revised textthe LTC EDI system (via MEDI or REV) when Medicare-covered SNF services end.
  3. (FCRC) Revised textEnters information from the facility in MMIS LTC subsystem.

    Revised textOptional: Revises Form 2449 based on information from the facility.

  4. (Medicare) Pays a Medicare certified facility for Medicare-covered SNF services provided to a customer who is a beneficiary eligible for such service during any part of the benefit period.
    • For the first 20 days, pays the allowable charges; and
    • for up to 80 more days, pays part of the charges with the customer responsible for his or her patient credit amount and HFS paying the coinsurance amount, if any, as determined by the Department.

      NOTE: The number of days a person receives covered SNF benefits depends upon one or more of the following: 

      • diagnosis by the physician;
      • certification by the attending physician that need for the services continues;
      • reversal by the Medicare intermediary or SSA of one of the above.
    • Example: Mr. S is admitted to a Medicare-certified SNF facility. The FCRC is notified that full Medicare coverage starts 05/01 and continues through 05/20, unless other changes occur. The coinsurance period begins 05/21 and continues for up to 80 days in the benefit period
  5. (CO) Pays the coinsurance amount, if any, as determined by HFS.
  6. (FCRC) Apply the customer's nonexempt income available during the calendar month of the billing period in which Medicare-covered SNF services were received, except for QMB eligible persons.
  7. (FCRC) Figure available income during the calendar month of the billing period when the customer received Medicare-covered SNF services.
  8. (FCRC) Revised textAs the admission date, enter in the MMIS LTC subsystem the latest of:
    • admission date; or
    • screening, if required; or
    • effective date of medical eligibility.
    • Revised textOptional: Enter the admission on Form 2299.
  9. (FCRC) Enter the patient credit amount in New textthe MMIS LTC subsystem

    Revised textOptional: Enter the patient credit amount in Section C of Form 2299 for new admissions and Section C of Form 2449 to add or correct information.

  10. (FCRC) Revised textWhen Medicare-covered SNF services end, enter in the MMIS LTC subsystem.
  • Revised textOptional: Revise Form 2449 when Medicare-covered SNF services end.
  • Example 1: Ms. S is admitted from a hospital to a Medicare certified SNF facility. The FCRC is notified that full Medicare coverage starts 06/01 and continues through 06/20, unless other changes occur. The coinsurance period begins on 06/21 and continues for up to 80 days
  • New textEnter admit authorization effective 06/01 and COS 65 in the MMIS LTC subsystem
  • Revised textOptional: Initiate Form 2299 with an admit authorization effective 06/01. Enter the effective date of 06/01 and COS 65 in Section D
  • New textEnter 06/21 start date of the coinsurance period and COS 72 in the MMIS LTC subsystem. The coinsurance amount, if any, is automatically considered until a revision is entered in the LTC subsystem or submitted on Form 2449 (optional).
  • Revised textOptional: Complete Form 2449 when the coinsurance period starts. Enter the effective date of 06/21 and COS 72 in Section D.
  • Example 2: Mr. J is transferred to a Medicare certified bed. The FCRC is notified that full Medicare coverage begins 04/15 and continues through 05/04 unless other changes occur. The coinsurance period begins on 05/05 and continues for up to 80 days
  • New textEnter the effective date of 04/15 and COS 65 in the MMIS LTC subsystem
  • Revised textOptional: Enter the effective date of 04/15 and COS 65 in Section D of Form 2449
  • New textWhen the coinsurance period begins, enter the effective date of 05/05 and COS 72 in the MMIS LTC subsystem. The coinsurance amount is automatically considered until a revision is entered in the LTC subsystem or submitted on Form 2449 (optional).
  • Revised textOptional: Complete a second Form 2449 when the coinsurance period begins. Enter the effective date of 05/05 and COS 72 in Section D.

Full Medicare Days Over Maximum Allowed

  1. (CO) As part of generating the monthly prepayment form, identifies cases that have an open COS 65, Full Medicare Coverage, for 20 or more consecutive days.
    • Lists the identified cases monthly on FCRC-specific report titled "Open LTC Cases For COS 65 and 72 Greater Than Allowable Days."
    • Sends report to the appropriate FCRC.
  2. (FCRC) Request that facility Revised textenter the correct end date for COS 65 and any changes in services in Revised textthe LTC EDI system (via MEDI or REV).
  3. (Facility) Revised textUsing MEDI or REV, notifies FCRC of the begin and end dates of Medicare-covered SNF services and any changes in services.
  4. (Facility) Within 30 days of receipt of the report, revise Revised textthe MMIS LTC subsystem to close COS 65 and add the correct COSDeleted text.

Medicare Coinsurance Days Over Maximum Allowed

  1. (CO) As part of generating the monthly prepayment form, identifies cases that have an open COS 72, Medicare Coinsurance, for 80 or more consecutive days.
    • Lists identified cases on the monthly FCRC specific report titled "Open LTC Cases For COS 65 and 72 Greater Than Allowable Days."
    • Sends report to the appropriate FCRC.
    • For identified cases (excluding QMB Only), enters a close date on the 80th day of COS 72. Opens a new level of care with COS 70, Skilled, effective with the day following the close date of COS 72.

      Revised textOptional: Generate Form 2449 reflecting the changes and send to FCRC.

  2. (FCRC) Request that facility Revised textenter the correct end date for COS 72 and any changes in services in Revised textthe LTC EDI system (via MEDI or REV).
  3. (Facility) Notifies FCRC of the begin and end dates of Medicare-covered SNF services and any changes in services using Revised textthe LTC EDI system (via MEDI or REV).
  4. (FCRC) For QMB Only identified cases and within 30 days of receipt of the report:
    • Revised textTo close COS 72 based on information Revised textsubmitted viv MEDI or REV, enter in MMIS LTC subsystem.

      Revised textOptional: Revise Form 2449 to close COS 72 based on information on Form 1156.

    • Process a discharge transaction effective with the day following the close date of COS 72.
  5. (FCRC) For identified cases (excluding QMB Only) and within 30 days of receipt of the report:
    • If Medicare-covered SNF services ended earlier than day 80 and/or the customer is no longer receiving a skilled level of care, Revised textenter revisions in MMIS LTC subsystem (optional: revise Form 2449) as needed to:
      • correct the close date for COS 72, Medicare Coinsurance;
      • correct the begin date for COS 70, Skilled; and
      • enter the correct COS for the services received, if appropriate.
    • If information on Form 1156 indicates the central office action taken in Item #1 is correct, no further action is required.

Handling Income

Monthly countable income is only applied toward Medicare-covered SNF charges or Medicaid services for that month's billing period. Any remaining amount belongs to the customer and may be used or saved, as the customer or guardian chooses, without affecting medical eligibility. When income remains after the month it was received, it must be treated as a Revised textresource.

  1. (FCRC) Verify Revised textresources at the end of a period of Medicare-covered SNF services.
  2. (FCRC) Budget excess Revised textresources when the disregard is exceeded.
  3. (FCRC) Notify customer about change in the amount of resources available to be used for care.
  • Example: Mr. J is transferred to a Medicare certified bed. The FCRC is notified that he is entitled to Medicare-covered SNF services. He receives $700 per month in Social Security benefits.
  • Full Medicare coverage begins 06/01 and continues through 06/20 unless other changes occur. The coinsurance period of up to 80 days starts 06/21.
  • Mr. J's condition changes and he is transferred to a non-Medicare covered SNF level of care on 07/27. The FCRC is notified that the coinsurance period ends on 07/27.
  • For June:
  • Apply income received in June toward the June billing period of 06/01 to 06/30:
    • Enter 06/01 in Revised textthe MMIS LTC subsystem with the credit amount of $670 ($700 - $30 = $670). (Optional: Complete Form 2449 and enter in Section C.)
    • Enter the effective date of 06/01 and COS 65 in Revised textthe MMIS LTC subsystem. (Optional: Complete Form 2449 and enter in Section D.)
  • Revised textWhen full Medicare-covered SNF services end, enter the effective date of 06/21 and COS 72 in the MMIS LTC subsystem. (Optional: Complete Form 2449 and enter the effective date of 06/21 and COS 72 in Section D.)
  • Medicare pays allowable charges for 06/01 through 06/20. The resident is responsible for the patient credit amount and the Department pays the coinsurance amount, if any, as determined by HFS for 06/21 through 06/30.
  • NOTE: If Mr. J was also eligible for QMB benefits, countable income would not be applied during the coinsurance period.
  • For July:
  • Apply income received in July toward the July billing period of 07/01 through 07/31. HFS pays the coinsurance amount, if any, for 07/01 through 07/26.
  • Revised textWhen Medicare-covered SNF services end on 07/26, enter the effective date of 07/27 and COS 70 in the MMIS LTC subsystem. (Optional: Complete Form 2449 when Medicare-covered SNF services end on 07/26.)