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Wisconsin Department of Health and Family Services Obsolete Medicaid Eligibility Handbook For the current MEH, see http://www.emhandbooks.wi.gov/meh-ebd/ For the current BC Plus Handbook, see http://www.emhandbooks.wi.gov/bcplus/ |
5.8.7.3.2 Community and Nursing Home
5.8.7.4 Transfers Between Institutions
5.8.7.4.1 Transfer between Nursing Homes
5.8.7.4.2 Nursing Home and Hospital
5.8.7.4.3 Multiple Nursing Homes and a Hospital
5.8.7.5 Retroactive Cost of Care
5.8.7.6 Personal Needs Allowance
5.8.7.7 Payment for Non-Covered Services
After you have determined that an institutionalized person is eligible for MA, you must calculate his/her cost of care. Cost of care is the amount s/he will pay each month to partially offset the cost of his/her MA services. It is called the patient liability amount when applied to a nursing home resident, and cost share when applied to a community waivers client, Pace/ Partnership, or Family Care client.
Calculate the cost of care in the following way:
For a MA client in a nursing home who does not have a community spouse, subtract the following from the person’s monthly income Income is anything you receive in cash or in kind that you can use to meet your needs for food, clothing, and shelter.:
$65 and ½ earned income disregard (4.1.3.6).
Monthly cost for health insurance (5.8.6.3).
Support payments (4.1.3.2.1).
Personal needs allowance (8.1.5.1).
Home maintenance costs, if applicable (4.1.3.1).
Expenses for establishing and maintaining a court-ordered guardianship or protective placement, including court-ordered attorney and/or guardian fees (4.1.3.2.3).
For a MA client in a nursing home who has a community spouse, follow the directions in 5.10.
For a community waivers client with or without a community spouse, follow the directions in 5.9.
For a hospitalized person, there is no cost of care. There is no system available yet to collect a hospitalized person’s cost of care.
There is no cost of care for SSI recipients.
For a MA client who was or could have been certified through a deductible before entering the institution, there is no cost of care until the deductible period ends.
If the cost of care amount is equal to or more than the nursing home’s Medicaid rate, the individual is responsible for the entire cost of his/her institutional care. S/he would be entitled to keep any overage without restriction. S/he would remain eligible for the Medicaid program and have no further financial obligation to the Medicaid program for that month.
Do not calculate or report a patient liability for a hospitalized person. See 5.8.7.4.2 and 5.8.7.4.3 for information about patient liability calculations when a person transfers between a hospital and nursing home(s).
Payment procedures are different for institutionalized Family Care or Pace/Partnership clients. These clients pay their cost share to the Managed Care Program instead of to the nursing home. The program then pays the nursing home.
If a client is not MA eligible and residing in an institution (5.8.1) as of the first of the month, there is no patient liability for that month.
Exception: There is a patient liability if the reason why the person didn't reside in the institution for the entire month was due to death or being on Theraputic leave.
If the patient liability amount in the month of death is greater than the nursing home’s cost of care for that month send a completed HCF 10110 ( formerly DES 3070 ) form to:
Mail: EDS
P.O. Box 7636
Madison, WI 53707
E-mail: veds@wisconsin.gov
Fax: (608) 221-8815
Indicate the patient liability amount as equal to the nursing home charges for the month. This is done for potential retroactive nursing home rate adjustments. The nursing home will notify the Estate Recovery Program ( ERP ) of who received the excess income. ERP will attempt recovery even if the money goes to the heir directly. ERP uses the same process to recover this excess income as it does for recovering patient fund accounts (6.1.5.7).
There is no patient liability in a month a client moves from:
The community into a nursing home after the first of the month, or
From a nursing home to the community before the end of the month.
When an institutionalized person transfers between institutions, calculate the patient liability due each institution. Send a completed Notice to Institutions, Nursing Home, Client form (HCF 10108) to notify the client and institution. Return a completed Medicaid/BadgerCare Certification form (HCF 10110, formerly DES 3070) to EDS.
If a client transfers between nursing homes, follow this procedure to divide the patient liability amount between them:
Divide the monthly patient liability amount by the number of days in the month of change. This results in the daily prorated amount.
Multiply the daily prorated amount by the number of days in the month of change that s/he resided in the first nursing home. Allocate the resulting amount to the first nursing home.
Multiply the daily prorated amount by the number of days in the month of change that s/he resided in the second nursing home. Allocate the resulting amount to the second nursing home.
Note: Do not count the day of the move twice. Count it for the nursing home to which s/he moved.
The entire patient liability amount for the month of the move is paid to the nursing home when a client moves from a nursing home to a hospital and has been continuously institutionalized for 30 days or more
For an applicant that was institionalized for the entire month and moves from a hospital to a nursing home during that month any patient liability would go to the nursing home.
For a recipient who is institionalized for an entire month and moves from a hospital to a nursing home, there is no patient liability obligation until timely notice requirements are met. (The reason for this is that hosptialized individuals are not required to contribute to their cost of care. This indiviudal is moving from a living arrangement that does not have a patient liability obligation to one that does.)
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Example: Jack had a stroke in early March 2004. Jack's condition stabilized and on March 17th, 2004, after adverse action, he was moved from a hospital to Prairie View Nursing Home. Because the move occurred after adverse action in March and timely notice requirements must be met, Prairie View Nursing Home will not be able to collect patient liability until May 2004. |
If a client moves from a nursing home to a hospital to a second nursing home, do not apply the income to the patient liability while in the hospital. The income is divided differently according to the timing of the moves.
If the client resides in two different nursing homes and a hospital all in the same month, divide the hospital days evenly and allocate those days to each nursing home. Then do the prorated calculation described in 5.8.7.4.1.
Send a Notice to Institutions, a Nursing Home, Client form ( HCF 10108 ) to the client and the nursing homes. If the move to the hospital is mid-month and then to the second nursing home is in another month, the first nursing home gets the entire liability amount for month one and the second nursing home gets the entire liability amount for month two.
Occasionally a nursing home or community waivers applicant becomes retroactively eligible. This might happen, for example, when a person, having been denied eligibility, goes to a fair hearing. If the fair hearing determines the person was eligible at the time of application, the agency must retroactively certify him/her and compute retroactive cost of care. The directions are the same as for current cost of care (5.8.7).
Deduct the personal needs allowance (8.1.5.1) for all institutionalized clients in both the eligibility test and the patient liability calculation.
MA clients in nursing homes are allowed to pay for some medically necessary non-covered services out of their patient liability. They are not required to use their personal needs allowance for these services. Refer clients to their provider to make this adjustment.
This page last updated in Release Number: 07-05
Release Date: 07/10/07
Effective Date: 07/10/07