Revision 18-1; Effective March 1, 2018

 

An institutional setting is a living arrangement in which a person applying for or receiving Medicaid lives in a Medicaid-certified long-term care facility or receives services under a Home and Community-Based Services waiver program. See Section G-6200, Special Income Limit for the Eligibility Budget.

To qualify for the special income limit, a person or couple must:

  • have countable income that exceeds the reduced Supplemental Security Income federal benefit rate;
  • receive a level of care or medical necessity determination that qualifies the person or couple for Medicaid; and
  • reside in:
    • a Medicaid-certified long-term care facility for 30 consecutive days; or
    • a Medicaid-certified institution for mental diseases for 30 consecutive days, if the person is age 65 or older,

For Medicaid under a Home and Community-Based Services waiver program, the person must be approved by a Texas health and human services agency to receive services for a waiver program and receive the services within one month after approval. The count of the 30 consecutive days starts at either:

  • entry into a Medicaid-certified long-term care facility and the person moves into an approval status for a waiver program; or
  • an approval to receive services under a waiver program and receive the services within one month after approval.

The 30 consecutive days are not disrupted if the person:

  • makes a three-day therapeutic home visit with a planned return to the facility;
  • is admitted to a hospital with a planned return to the facility; or
  • moves from a Medicaid-certified long-term care facility:
    • to a Home and Community-Based Services waiver program; or
    • to another Medicaid-certified facility.

If a person dies before meeting the 30-consecutive-day requirement without moving to a noninstitutional setting, the person is considered to have met the requirement for application of the special income limit.

Note: Consider potential retroactive coverage for the three months prior to the date of application if the person entered a nursing facility, ICF/ID or state supported living center and then transitioned into a waiver setting before being certified. Use the special income limit for the month of entry to the Medicaid-certified long-term care facility (Medicare-SNF, NF or ICF/ID) if it is anticipated that the person will remain in a Medicaid-certified long-term care facility for at least 30 consecutive days. When eligibility is based on the special income limit, finalization of the person’s eligibility cannot be processed or disposed in the system of record until the 30 consecutive days have been met.

 

O-5100 Waiver Co-Payment

Revision 18-1; Effective March 1, 2018

 

In order to comply with the federally approved waiver, co-payment must be considered for waiver persons whose eligibility is determined under the special income limit. See Appendix XXII, Home and Community-Based Services Waiver Program Co-Payment Worksheets, for the sequence in which deductions are allowed. Allow deductions indicated on the appropriate co-payment worksheet. For many waiver persons, the co-payment will be $0. Notify HHSC of the co-payment amount using Form H2067, Case Information, or use the MEPD communication tool (http://dadsview.dads.state.tx.us/me-to-dads/). If the person is married and applying for waiver eligibility, use spousal impoverishment policy for consideration of resources. Spousal impoverishment policy is not used in the TxHmL Program.

 

O-5200 Medicare and Co-Payment

Revision 09-4; Effective December 1, 2009

 

Under certain limited conditions, Medicare will pay some nursing facility (NF) costs for Medicare beneficiaries who require skilled nursing or rehabilitation services. To be covered, the person must receive the services from a Medicare-certified skilled nursing facility (SNF) after a qualifying hospital stay. A qualifying hospital stay is the amount of time spent in a hospital just before entering a nursing facility. This is at least three days. Care must begin within 30 days after leaving the hospital. The person’s doctor must order daily skilled nursing or rehabilitation services that the person can get only in an SNF. "Daily" means seven days a week for skilled nursing services and five days a week or more for skilled rehabilitation services.

 

Number of Days Person's Responsibility Medicare's Responsibility
1-20 Nothing Everything
21-100 20% — the SNF care co-payment per day paid after 20 days of Care (21-100). See Appendix XXXI, Budget Reference Chart. The rest
Over 100 Everything Nothing

 

O-5210 Medicaid Coverage Code Issues

Revision 12-2; Effective June 1, 2012

 

  • T coverage code is not a Medicaid coverage code. T indicates Community Attendant Services (CAS) coverage providing Medicaid payment for attendant care only. This coverage code does not provide for NF vendor payment, doctor visits, hospital stays, medically necessary items or prescription drug coverage.
  • R coverage code is a Medicaid coverage code. R indicates regular Medicaid coverage providing Medicaid payment for NF vendor payment, doctor visits, hospital stays, medically necessary items or prescription coverage. Medicaid is the payer of last resort and a medical necessity is required for vendor payment in an NF. Vendor payment is also subject to co-payments. R coverage provides for payment of prescription drug coverage except when the person is dually eligible for both Medicare and Medicaid.
  • Q coverage code is a Qualified Medicare Beneficiary coverage code. Q indicates that Medicaid pays the Medicare premiums, deductibles and co-insurance, including Medicare-covered hospital and NF stays.

 

Examples

Example 1: When a person with only coverage code Q (only active EDG is MC – QMB – also known as a Pure Q) enters an SNF from a hospital, Medicare will cover 100% of the SNF vendor costs for days 1-20. Medicare will cover 80 percent of the SNF vendor costs for days 21-100. As a Pure Q person, Medicaid's Q covers 100 percent of the remaining 20% of the SNF vendor costs for days 21-100. The person will not be responsible for the remaining 20% of the SNF vendor costs – the Medicare co-pay per day for days 21-100. As a Pure Q person, the person is not responsible for the amount of co-payment an MEPD-eligible individual must pay for nursing care.

Note: If the person does not remain a Pure Q person and becomes certified for MEPD, use Example 2.

Example 2: When a person living in the community enters an SNF from a hospital and is dually eligible for both Medicare and Medicaid (MQMB with both R and Q coverage), Medicare will cover 100% of the SNF vendor costs for days 1-20. Even though the person is MEPD eligible, test the person for institutional coverage that is subject to transfer of assets and excess home equity policy. The 30-day stay requirement is not necessary. If the person is eligible for MEPD and co-payment:

  • retroactive adjustments to ensure the correct benefits will be necessary;
  • the person will not be responsible for the remaining 20% of the SNF vendor costs – the Medicare co-pay per day for days 21-100; and
  • the person will have a calculated MEPD co-payment beginning day 21.

Notify the person of the responsibility for the MEPD co-payment.

Example 3: When a CAS person (T coverage code only) who has Medicare enters an SNF from a hospital, Medicare will cover 100% of the SNF vendor payment for days 1-20. Medicare will cover 80% for days 21-100. The person’s MEPD eligibility in an NF (R coverage) needs to be determined. Test the person for institutional coverage that is subject to transfer of assets and excess home equity policy. The 30-day stay requirement is necessary. If the person is eligible for MEPD with co-payment:

  • retroactive adjustments to ensure the correct benefits will be necessary;
  • the person will not be responsible for the remaining 20% of the SNF vendor costs – the Medicare co-pay per day for days 21-100; and
  • the person will have a calculated MEPD co-payment beginning day 21.

Notify the person of the responsibility for the MEPD co-payment.

Example 4: When a CAS recipient with Qualified Medicare Beneficiary (QMB) only (T and Q coverage codes) enters an SNF from a hospital, Medicare will cover 100% of the SNF vendor payment for days 1-20. Medicare will cover 80% for days 21-100. The person's MEPD eligibility in an NF (R coverage) needs to be determined. Test the person for institutional coverage that is subject to transfer of assets and excess home equity policy. The 30-day stay requirement is necessary. If the person is MEPD eligible for vendor payment:

  • retroactive adjustments to ensure the correct benefits will be necessary;
  • the person will not be responsible for the remaining 20% of the SNF vendor costs – the Medicare co-pay per day for days 21-100; and
  • the person will have a calculated MEPD co-payment beginning day 21.

Notify the person of the responsibility for the MEPD co-payment.

If the person is not MEPD eligible for vendor payment but is eligible for Pure Q, notify the person and use Example 1.