PM 15-06-03-b.

Only apply the procedures in this sub-topic to a client who enters an LTC or SLF facility directly from the community. This includes a community client who enters an LTC or SLF facility following a hospital stay.

Figure eligibility for Medical separately from person(s) in the home when a person becomes a resident of an LTC or SLF facility. Refigure eligibility beginning the first full month in the facility.

Example: A husband and wife live together and receive Medical. Their eligibility is figured on a Community Standard for 2 persons. The wife becomes ill and enters an LTC facility. Her eligibility for Medical is figured by comparing her income to the LTC/SLF Standard of $30. Her husband's income is not applied toward the cost of her care. The husband's continuing eligibility for Medical is figured on the monthly Community Standard for one person. Change the standard beginning with the first full month of the change in circumstances.

See WAG 26-04-07 for how to complete Long Term Care Authorization (Form 2299). See WAG 26-04-08 for how to complete Long Term Care Update Authorization (Form 2449).

Use Form 2500 to figure income and nonexempt assets available to apply to LTC or SLF charges, when a Community client enters an LTC or SLF facility on the first day of the calendar month and remains in the facility for the entire calendar month.

  1. For the first full month the client is in the facility, update Item 80 of Form 552:
    • Delete the spenddown coding if the case was community spenddown.
    • Enter the monthly amount, if there is income to apply towards the cost of LTC or SLF care, following code 395 GCARE or 391 SPDGC.
    • Enter code 392 AST and the amount of nonexempt excess assets. If none, enter 0.00.

Use the Community Standard for the month of admission, when a Community Medical client (regular or spenddown, met or not met) enters an LTC or SLF facility after the first day of the calendar month.

  1. Complete Form 2382A.
    1. For the month of admission, disregard income in figuring the amount available to apply to the cost of care.
    2. Apply only the amount of excess nonexempt assets belonging to the client. Disregard assets the client has transferred or intends to transfer as the Community Spouse Asset Allowance (see WAG 07-02-22).
  2. Compare nonexempt assets to the asset limits.
    1. When nonexempt assets are less than or equal to the asset limits, there is no credit amount for the partial month of admission. If the spenddown was not met:
      • Place the case in met status as of the admission date to the facility.
      • Complete an admit action using Form 2299 to start HFS payment for the month of admission.
      • Change the case status to LTC or SLF credit or spenddown, based on the appropriate LTC or SLF standard, for the first full month of expected stay in the facility.

        Complete Form 2449 to process a discharge action in the MMIS LTC system if the case status is changed to LTC or SLF spenddown. Enter the first day of the first full month of stay in the facility as the discharge date.

        Example: On 07/10 Ms. A is admitted from the community to a long term care facility. Her monthly income is $600. There are no excess assets. The monthly private pay rate is $3,000.

        Ms. A has a community spenddown of $292 for July ($600 - $25 disregard - one person Community Standard = $292). If spenddown is not met on an earlier date, place the case in met status effective 07/10 (the admission date). Complete Form 552 using TA 31/TAR 55 to place the case in met status. Complete Form 2299 to start payment to the long term care facility, entering a long term care credit amount of 0.00 for July.

        Complete Form 2500 for August, the first full month of stay in the facility. Change the case status to long term care credit by coding Form 552 with TA 31/TAR 57 to delete the spenddown code and add the long term care credit code. Enter the long term care credit amount in the MMIS LTC system effective for August. 

    2. When nonexempt assets are greater than the asset limits, determine if spenddown is met for the partial month of admission.

Compare excess nonexempt assets to the cost of care at the private rate or the HFS rate, whichever is greater.

Excess Nonexempt Assets are Less Than or Equal to the Cost of Care

For the month of admission, if spenddown is not met before the admission date, place the case in spenddown met status as of the admission date to the facility.

Complete Form 2299 to start HFS payment for the month of admission.

The credit amount for the month of admission is the amount of excess nonexempt assets.

Change the case status to credit or spenddown, based on completion of Form 2500, for the first full month of stay in the facility.

Complete a Form 2449 to process a discharge action in the MMIS LTC system if the case status is changed to spenddown. Enter the discharge date as the first day of the first full month of stay in the facility.

Example: Mr. B is enrolled for spenddown (not met) and is admitted from the community to a long term care facility on 06/04. He receives monthly income of $650 and has excess nonexempt assets of $1,000. The private pay rate is $100 a day.

Mr. B has a spenddown for June that includes $1,000 excess nonexempt assets. If spenddown is not met on an earlier date, determine if spenddown is met on the date of admission. Since excess nonexempt assets ($1,000) are less than the private rate charges for the month ($100/day X 27 days = $2,700), place the case in met status effective 06/04.

Complete Form 552, using TA 31/TAR 55 to place the case in met status.

Complete Form 2299 to start payment to the long term care facility. Enter a long term care credit amount of $1,000 for June.

Change the case status to long term care credit for July, based on completion of Form 2500. Since all excess nonexempt assets were applied to the cost of care for June, figure the long term care credit amount using only monthly income.

Complete Form 552 using TA 31/TAR 57 to delete the spenddown code and add the long term care credit code. Enter the long term care credit amount ($650 - $30 = $620) in the MMIS LTC system for July.

Excess Nonexempt Assets More Than Cost of Care

When nonexempt assets are more than the cost of care, do not place the case in met status as of the admission date to the facility.

Do not start HFS payment for LTC or SLF charges for the month of admission.

Change the case to LTC or SLF credit or spenddown, based on the appropriate LTC or SLF Standard for the first full month of stay in the facility.

Example: Mrs. C is enrolled for spenddown (not met) and is admitted from the community to a long term care facility on 09/15. Her monthly income is $700. She has excess nonexempt assets of $9,000. The monthly private rate is $3,000 ($100/day).

Mrs. C has a community spenddown for September that includes $9,000 excess nonexempt assets. If spenddown is not met on an earlier date, determine if spenddown is met on the date of admission. Since excess nonexempt assets ($9,000) are greater than private rate charges for the month ($100/day X 16 days = $1,600), do not place the case in met status as of the admission date to the facility. Do not start HFS payment for the month of admission.

Complete Form 2500 for October and change the case status to long term care spenddown. Complete Form 552, using TA 31/TAR 57, to delete Item 80 code 390 SPD and to enter Item 80 code 391 SPD GC. Do not start HFS payment until spenddown is met.

Do not complete Split Billing Transmittal for MANG spenddown Program (Form 2432) for LTC or SLF charges incurred on the date of admission.

To figure if HFS is to make payment on other medical costs for the month of admission, compare allowable medical costs incurred or paid on or before the date of admission to the spenddown amount.

Do not count LTC or SLF charges for the month of admission towards the community spenddown.

Complete Form 2432 for any other medical costs for which HFS is to make payment when the community spenddown is met on the date of admission.

Use the Community Standard for the month the person left the facility if an approved LTC or SLF client returns to the community.