Provisional Eligibility for Nursing Home and Supportive Living Program Services

Helping Families. Supporting Communities. Empowering Individuals.
Illinois Department of Human Services
Illinois Department of Healthcare and Family Services

03/28/19

Policy Memo

Summary: Authorization of Provisional Eligibility (PE) is available when there is a delay in LTC application processing or payment of LTC services to providers.

  • HFS authorizes PE for persons whose nursing home or supportive living program admissions are pending for 45 days or longer and the person has:
    • A pending over 45 days medical application; or
    • An active medical case.
  • HFS authorizes PE by systematically entering admissions into the LTC subsystem and adding a Special Eligibility segment with a new MANG P code to MMIS. Persons granted PE will be enrolled in Managed Care as per current rules. HFS does not make any updates in IES, including adding case comments or uploading notices when PE is authorized.
  • Persons authorized for PE are sent notifications of the date PE begins and ends.

New MANG P Code in MMIS

A new MANG P code (MK) has been established to allow payment to providers for persons who do not have a certified LTC EDG at the time PE is added. MK appears on the MMIS eligibility inquiry screen in the section titled, Presumptive Eligibility/Temporary Medical Benefits.

The MK code is added when an admission pends over 45 days and the person has:

  • An application pending over 45 days;
  • An active medical case with no LTC EDG; or
  • An active medical case at the time of the admission but their medical eligibility has since ended.

HFS adds an end date to the MK code in MMIS when a person is approved or denied for nursing home or supportive living program services. For any portion of the PE period for which LTC eligibility is granted HFS will change the MANG P code of (MK) to an (MJ) to indicate the portion of the PE period that is now claimable.

Managed Care Enrollment for PE

Individuals that had community Medicaid eligibility prior to being granted the PE for LTC may already have been enrolled in in Managed Care. These individuals can remain enrolled. Individuals who are given PE who have no other eligibility will not be enrolled into Managed Care until an actual eligibility determination is made.

HFS Entries into LTC Subsystem

HFS runs a list of pending over 45 days admissions (TANs) on the 15th of each month and subsequently begins adding admissions into the LTC subsystem. First HFS sorts the TANs to identify:

  • Duplicates;
  • TANs with no pending application or active medical case; and
  • TANs pending due to resource spenddown or penalty period.

HFS updates the TAN status code as follows:

  • 15 to pend the TAN when HFS adds an admission segment into the LTC subsystem;
  • 16 to reject duplicate TANs; and
  • 16 to reject TANs submitted with no pending application after 90 days.

New status codes 15 and 16 are for HFS use only.

TANs given a pending status of 15 must still be reviewed by the DHS caseworker to update the LTC information in both IES and MMIS, which includes running the group care credit calculations and updating the patient credit amount. Once DHS has completed the review of the TAN the caseworker should update the status of the TAN from 16 to a final status, such as completed. See additional information below.

TANs with a pending status code of 15 will still appear on the LTC EDI Transactions Aged Report # A2735KK1 until a final non-pending status is given.

TANs given a rejected status of 16 will not appear on the LTC EDI Transactions Aged Report. LTC Providers will be notified of the TANs rejected with a status code of 16 via a letter sent by HFS.

Admissions Entered by HFS with PE

HFS will enter admissions for persons authorized for PE into the LTC subsystem. HFS will use:

  • PPP as the caseload ID; and
  • Information available in IES to estimate the patient credit amount.

Admissions Entered by HFS without PE

HFS will enter admissions into the LTC subsystem without authorizing PE when a person has a certified LTC EDG or ACA EDG with LTC indicator.

HFS will use:

  • Repetitive numbers or letters in various data fields (caseload ID, LTC ID, Phys #, etc.); and
  • Information available in IES to estimate the patient credit amount.

Admission Date

HFS assigns the admission date based on the admission date reported on the TAN and timely filing rules when the person has:

  • An active medical case for the requested admission date; or
  • A pending application that can be backdated to the admission date.

HFS will also enter a discharge date when known or derived based off a subsequent admission.

Correcting the Admission/Discharge Dates entered by HFS

Email a completed change request form to the BLTC at HFS.LTC@illinois.gov when the admit or discharge date entered by HFS into the LTC subsystem is incorrect.

Remember to review time line rules before sending a request to correct an admission date that "appears" to be incorrect.

Do not send a request to delete an admission date to the BLTC when a screening is needed, but not provided, with the admission transaction. The correct actions to take by the worker are to discharge the individual the same day of decision, using the discharge destination code of D9 (other), reject the admission TAN with status code 12 and send a rejection letter to the provider.

Caseworker Actions

Determine Medical Eligibility and Approval for Payment of LTC Services

Authorization of PE does not replace the caseworker's role of processing the application and request for approval to pay for LTC services.

Persons authorized for PE must still comply with requirements that apply to determination of medical eligibility and approval for payment of LTC services. The caseworker continues to process the person's application for medical benefits and request for approval to pay for LTC services by applying established policy and procedures, completing the appropriate data fields in IES including running eligibility and certifying the case.

Update the LTC Subsystem

Updating the PE segment in the LTC subsystem varies depending on whether the decision on the application or request for LTC services is a/an:

  • Denial;
  • Approval without a resource spenddown or penalty period;
  • Approval with a resource spenddown or penalty period; or
  • Approval with a resource spenddown plus penalty period.

Updates to the LTC subsystem may include:

  • Correcting the patient credit amount entered by HFS, and/or
  • Entering a discharge date and discharge code.

Discharges

HFS will discharge the person for date of death if the information is available at the time the admission is added. When the person is deceased and the discharge has not been entered in the LTC payment system by HFS, enter the discharge using the date of death and discharge destination code D1.

Facilities are required to enter discharge dates in MEDI. When the person has discharged (hospital, community, etc.) and the facility has not entered the discharge information, enter the discharge using the day of discharge and appropriate discharge code.

When a TAN is rejected due to missing screening information, the caseworker should discharge the individual the same day of decision. The correct actions to take by the caseworker are:

  • Discharge the individual the same day of decision, using the discharge destination code of D9 (other);
  • Reject the admission TAN with status code 12;
  • Complete and send IL 444-1010 Admit Rejection Letter to the provider; and
  • Upload a copy of the rejection letter to the ECR.

TAN Status Code Entries by Caseworker

HFS enters the TAN status code of 15 when PE is authorized. Status code 15 only pends the admission in the TAN database until the caseworker makes a decision on the application or a request for approval to pay for services.

It is important to remember to appropriately update the TAN status code after making a decision on the application or a request for approval to pay for services. Updating the TAN status code helps HFS identify and avoid authorizing PE for cases approved with resource spenddown and penalty periods.

Use the appropriate status code when the application or request for approval to pay is approved or denied.

Approval:

  • Without a resource spenddown and/or penalty period use status code 13;
  • With a resource spenddown use status code 01;
  • With a penalty period use status code 02; or
  • With both resource spenddown and penalty period use status code 01.

Denial:

  •  Use status code 12.

Determine Eligibility and Certify Results in IES

Apply policy and procedures to determine the person's medical eligibility (approval, denial) at intake.

Apply policy and procedures to determine if the person meets or doesn't meet requirements to be approved for payment of LTC services when the person has an active case at the time they are admitted to a nursing home or supportive living program.

PE and Resource Spenddown

The resource spenddown begin month is adjusted to the month following the month of decision for cases that have been authorized PE and the case has a LTC NH/SLP SPD EDG for any month(s) during the certification period.

A LTC NH/SLP SPD EDG is established when countable income plus excess resources (resources over the resource limit) exceed the facility private pay rate. 

Determining Resource Spenddown Amount

Take the following steps before certifying a case that has at least one LTC NH/SLP SPD EDG after running eligibility (Eligibility Summary):

Step 1

Review non-exempt resource verification(s) already uploaded to the ECR to determine if the verification(s) are current. Consider verification(s) dated within two months prior to the month of decision to be current.

  • Proceed to Step 3 when current nonexempt resource verification(s) are available at the time of decision
  • Proceed to Step 2 when current nonexempt resource verification(s) are not available at the time of decision.

Step 2

Send a VCL requesting current nonexempt resource verification(s).

  • Allow 10 days to return the verifications, (do not grant extensions);
  • Monitor the VCL due date; and
  • Proceed to Step 3.

Note: Do not deny the application if requested resource verifications are not provided.

Step 3

Resource Verifications Already Available or Received

  • Delete the resource record(s)
  • Add a new resource record(s) using CSCD of the first day of the month following the month of decision;
  • Enter the verified nonexempt resource amount(s); and
  • Proceed to Step 4.

Resource Verifications are Not Received

  • Delete the resource record(s);
  • Add a new resource record(s) using CSCD of first day of the month following the month of decision;
  • Enter the nonexempt resource amount(s) using the "most recent" verified resource(s) documents uploaded to the ECR; and
  • Proceed to Step 4.

Note: "Most recent" is the oldest documentation with a date on or after the beginning month of eligibility including backdate months.

Step 4

  • Run Eligibility; and
  • Certify the case.

PE and Penalty Period

The penalty period begin date is adjusted to the first day of the month following the month of decision for cases that have been authorized PE when:

  • The case doesn't have LTC NH/SLP SPD EDG'S; and
  • The end month of the penalty period calculated by IES is after the month of decision.

Disregard penalty months that end prior to the month of decision for cases that have been authorized PE. Only penalty months that continue past the month of decision will be imposed. The begin date of any remaining penalty period months is the first day of the month following the month of decision.

After certifying the case, review the penalty period end date on the Level of Care Tab or the Resource Tab on the EDG Summary Screen to determine if the penalty period end date is:

  • Prior to the month of decision; or
  • After the month of decision.

Note: Disregard any partial month calculations

Send an email to BLTC at HFS.LTC@illinois.gov and request the OBRA begin and end dates in MMIS be corrected to reflect the adjusted penalty period, include the person's name and RIN.

PE and Resource Spenddown Plus Penalty Period

Contact the BMEP at HFS.DMP.PolicyQS@illinois.gov for guidance when a case is approved with a Resource Spenddown plus a Penalty Period and PE has been authorized for the case.

Updating the LTC Subsystem After the Case is Certified

Updating the PE segment in the LTC subsystem varies depending on whether the decision on the application or request for LTC services is:

  • Denial/requirements are not met;
  • Approval without a resource spenddown or penalty period;
  • Approval with a resource spenddown or penalty period; or
  • Approval with a resource spenddown plus penalty period.

Denial/Requirements are not met

Take the following actions in the LTC subsystem after the application is denied or requirements are not met to approve for payment of LTC services when the person already has an active case:

  • Enter the day following the date of decision as the discharge date;
  • Enter discharge code D9;
  • Correct the patient credit amount to $0.00 when an amount other than $0.00 is entered by HFS;
  • Update the TAN status code to 12;
  • Complete and send IL 444-1010 Admit Rejection Letter to the provider; and
  • Upload a copy of the rejection letter to the ECR.

Examples:

1. Ms. X applies for medical assistance on 02/01/17. At the time of application the facility submits the admission transaction with an admission date of 02/15/17. The admission transaction and the application pend over 45 days. HFS authorizes PE and adds the admission dated 02/15/17 into the LTC subsystem. HFS also enters an estimated patient credit amount of $0.00. On 06/10/18 the caseworker denies the medical application.

Caseworker actions in LTC subsystem include:

  • Enter a discharge date of 06/11/18;
  • Enter discharge code D9;
  • Update the TAN status to code 12;
  • Send rejection letter to facility; and
  • Upload copy of rejection letter to ECR.

Note: a correction to the patient credit amount is not required because it is already $0.00.

2. Mr.Y has had an active medical case in the community for 3 months when he moves to an SLP on 05/31/18. The provider submits the admission transaction with an admission date of 05/31/18. The admission transaction pends over 45 days so the admission dated 05/31/18 is entered into the LTC subsystem by HFS. HFS enters an estimated patient credit amount of $250.00. Mr. Y does not complete and return the HFS 3654 by 09/01/18 (due date). Because Mr. Y has not complied with the requirements to be approved for payment of LTC services, his case remains a community case with no LTC EDG.

Caseworker actions in LTC subsystem include:

  • Enter a discharge date of 06/11/18;
  • Enter discharge code D9;
  • Correct patient credit amount to $0.00 (starting 05/31/18 to date of discharge);
  • Update the TAN status to code 12;
  • Send rejection letter to facility; and
  • Upload copy of rejection letter to case.

Approvals/Requirements met

Take the following actions in the LTC subsystem after the application is approved or requirements are met to approve for payment of LTC services when the person already has an active case:

Approval Without a resource spenddown or penalty period:

  • Correct the patient credit amount to match the GCC amount calculated by IES; and
  • Update the TAN status code to 13.

Remember to enter appropriate patient credit segments to reflect community months and changes in income, if applicable. Review training material - Processing Admits, Changes and Discharges.

Example:

Mr. Z admits to a nursing home on 05/15/18 and applies for Medicaid on the same day. Mr. Z receives $1,500 in SSA income. The facility submits the admission TAN on 05/15/18. Mr. Z's admission and application pend over 45 days.

HFS authorizes PE and enters the admission into the LTC payments system with begin date 05/15/18. HFS uses the information in IES to estimate the GCC amount at $1,500. At the time HFS enters the admission the only information in IES is Mr. Z's income.

Mr. Z's application is approved on 09/24/18. After updating the facility detail page, the calculated GCC is $1,336 ($1,500 - $30 - $134).

Caseworker Actions in LTC subsystem include:

  • Correct the patient credit amount to $0.00 beginning 05/15/18 and ending 05/31/18 for the community month;
  • Add the ongoing patient credit amount of $1,336 beginning 06/01/18; and
  • Update the TAN status code to 13.

Approval with Resource Spenddown:

  • Enter the day following the date of decision as the discharge date;
  • Enter discharge code D9;
  • Correct the patient credit amount to $0.00 when an amount other than $0.00 has been entered by HFS; and
  • Update the TAN status code to 02.

Example:

Ms. O admits to a nursing home on 06/15/17 and applies for Medicaid on the same day. Ms. O's admission (facility submits TAN on date of admission) and application pend over 45 days. HFS authorizes PE and enters the admission into the LTC subsystem.

On 09/16/18, the caseworker is ready to process the application. After running eligibility, the Eligibility Summary page reveals that Ms. O has a LTC NH SPD EDG for 07/17 and 08/17 so the caseworker reviews the resource verifications in the ERC to determine if the resource verifications are current. The most current resource verification (bank statement) in the ECR is dated 03/01/18. The caseworker sends a VCL to request a current bank statement because the verifications in the ECR are not considered current (3 months old). Ms. O does not respond to the VCL by the due date so the caseworker uses the bank statement dated 03/01/18. The caseworker deletes the bank account resource and adds the bank account resource back using the CSCD of 10/01/18 and resource amount that is verified on the documentation dated 03/01/18, reruns eligibility and certifies the case.

Caseworker actions in LTC subsystem include:

  • Enter a discharge date of 10/01/18;
  • Enter discharge code D9;
  • Correct the patient credit amount to $0.00 when an amount other than $0.00 is entered by HFS; and
  • Update the TAN status code to 02.

Approval with Penalty Period

When the End Penalty Month is Prior to the Month of Decision

  • Correct the GCC amount to $0.00 for the penalty period months when an amount other than $0.00 has been entered by HFS;
  • Add the GCC amount calculated by IES beginning with the first day of the first month following the end penalty period month; and
  • Update the TAN status code to 13.

Note: Because the penalty ends prior to the month of decision, the caseworker does not enter a discharge or pend (01) the TAN status code due to penalty period.

Example:

Mrs. K moves to a supportive living program on 10/25/17 and applies for Medicaid on the same day. Mrs. K's admission (admission TAN submitted 10/25/17) and application pend over 45 days. HFS authorizes PE and enters the admission into the LTC subsystem. HFS enters $825 as the estimated patient credit amount beginning 10/25/17. Mrs. K gave some money to her grandchildren prior to applying for Medicaid so her application is approved on 06/19/18 with a penalty period. The end date of the penalty period calculated by IES is 01/31/18.

Caseworker Actions in LTC subsystem include:

  • Correct the patient credit amount to $0.00 beginning 10/25/17 and ending 01/31/18;
  • Add the patient credit amount figured by IES beginning 02/01/18; and
  • Update the TAN status code to 13.

When the End Penalty Month is After the Month of Decision

  • Correct the patient credit amount (GCC) to $0.00 when an amount other than $0.00 has been entered by HFS;
  • Enter the first day of the following month as the discharge date;
  • Enter discharge code D9; and
  • Update the TAN status code to 01.

Example:

Mrs. K moves to a supportive living program on 10/25/17 and applies for Medicaid on the same day. Ms. K's admission (admission TAN submitted 10/25/17) and application pend over 45 days. HFS authorizes PE and enters the admission into the LTC subsystem. HFS enters $825 as the estimated patient credit amount beginning 10/25/17. Mrs. K gave some money to her grandchildren prior to applying for Medicaid so her application is approved on 06/19/18 with a penalty period. The end date of the penalty period calculated by IES is 08/31/18.

Caseworker Actions in LTC subsystem include:

  • Correct the patient credit amount to $0.00;
  • Enter a discharge date of 07/01/18;
  • Enter discharge code D9; and
  • Update the TAN status code to 01.

Approval with Resource Spenddown Plus Penalty Period

Contact the BLTC for instructions on how to update the LTC subsystem when HFS authorizes PE and the case has a LTC NH/SLP SPD EDG plus a Penalty Period.

Track Approvals that Result in Entering a Discharge in the LTC Subsystem

Follow office procedures for tracking resource spenddown and penalty period end dates to re-admit the person when the person is discharged from the LTC subsystem because the person, authorized for PE, is approved with a resource spenddown or penalty period. Remember to clear the TAN when the admit is re-entered.

Adjustment to Notice of Decision when PE has been Authorized

Complete and send HFS 458LTC Notice of Decision on Application for Medical Assistance MANG LTC/SLF when a person is applying for medical benefits and LTC services and PE has been authorized on the case.

Enter the first day of the month following the month of decision in the "This is the decision made about your application for Medical Assistance dated" field.

Complete and send HFS 2500 LTC/SLF Resource Calculation when a person already has an active medical case, meets the requirements to approve payment for LTC services, and PE has been authorized. Complete and send IL 444-1010 Admit Rejection Letter when the person does not meet the requirements to approve payment for LTC services and PE has been authorized.

Temporary Medical vs Provisional Eligibility

Temporary Medical Benefits are issued for persons whose medical application pends beyond the legal time limit and the delay is determined to be agency delay. In order for a person to receive Temporary Medical Benefits the person has to request the benefits be issued. Temporary Medical Benefits do not include payment for LTC services. Temporary medical benefits systematically end if the individual is approved, if the individual is denied the caseworker must end temporary medical by sending a 2958 to EPU. The MANG P code used to identify temporary medical is MQ. If an individual has been granted Provisional Eligibility and has a MANG P code 'MK' on MMIS, then there is no need to process a Temporary Medical Benefit with a MANG P code of 'MQ'.

Provisional Eligibility is authorized for persons whose admission to a long term care facility pends over 45 days and the person has an active medical case or a medical application pending for over 45 days. PE is not requested, HFS automatically authorizes PE when the criteria is met. The authorization of PE includes payment for LTC services. PE ends when the application has been processed and a determination of LTC eligibility has been made, regardless of approved or denied.

Note: PE can be authorized for a person who has already been approved for Temporary Medical MANG P 'MQ'. The authorization of PE will result in the closing of the Temporary Medical MANG P 'MQ' segment one day prior to the begin date of the PE MANG P 'MK'.

Note: Any portion of the PE period that is approved for LTC eligibility will be charged to a MANG PO code of 'MJ' by HFS for reporting and claim purposes.

[signed copy on file]

Grace B. Hou

Secretary-Designate, Department of Human Services

Theresa Eagleson
Director, Healthcare and Family Services

Forms referenced

  • IL 444-1010
  • HFS 2500
  • HFS 458LTC