Section 208.010, RSMo, states in subsection 2.(7) that benefits are not payable to any claimant who 'is an inmate of a public institution, except as a patient in a public medical institution'.
Federal regulations prohibit payment of benefits to claimants, under age 65, in an institution for mental diseases or tuberculosis.
Federal regulations require the Family Support Division to establish agreements with State institutions providing treatment for mentally ill individuals, age 65 or older, for whom payment is made under the Missouri Medicaid State Plan.
The agreements between the State agencies and the State institutions are designed to assure a framework of cooperation between State entities, the Missouri Medicaid State Plan requirements are adhered to, and federal laws and regulations are observed.
NOTE: To determine the claimant's State of residence, refer to the policy on RESIDENCE Section 1015.000.00.
13 CSR 40-2.080 (1) defines a PUBLIC INSTITUTION As an institution which provides shelter or care to a person and is managed or controlled, in whole or in part, by or through a public instrumentality, official or employee acting in an official capacity. An inmate is defined as any person residing in an institution for the purpose of receiving inpatient care, whether they were committed to the institution or whether they are there on a voluntary basis. Persons who are inmates of the following types of public institutions are not eligible to receive public assistance:
Recipients entering any of the aforementioned institutions are not eligible to continue receiving assistance and assistance must be discontinued.
NOTE: The following are not inmates and are eligible for MO HealthNet, if all other eligibility is established.
NOTE: A person who is CONDITIONALLY RELEASED from a public mental hospital is not considered an inmate of a public institution since the person is free from continuous supervision by the hospital.
NOTE: Inmates who are admitted inpatient for 24 hours or more to a medical facility may be eligible for MO HealthNet benefits. The individual must meet all other eligibility factors for the specific program. Eligibility is limited to the days the inmate is inpatient in the medical facility. An inmate who is taken to the emergency room and admitted to the hospital as an inpatient with total stay of 24 hours or more will be eligible from the time the individual entered the emergency room.
While the law disqualifies persons who are inmates of certain public institutions from receiving assistance, there is an exception for persons who are 'patients' in public medical institutions. Regulation 13 CSR 40-2.080(3) defines 'patient', and regulation 13 CSR 40-2.080(4) defines 'public medical institution'.
The following criteria are applied when determining eligibility for patients in public medical institutions:
Persons age 65 or older in the certified sections of Fulton State Hospital, St. Joseph State Hospital, Nevada State Hospital, Farmington State Hospital, St. Louis State Hospital, Western Missouri Mental Health Center in Kansas City, Mid-Missouri Mental Health Center in Columbia, and Malcolm Bliss Mental Health Center in St. Louis meet the 'institutional residence' eligibility requirement.
Individuals under 65 in State Mental Hospitals or the Missouri State Rehabilitation Center, who meet the eligibility criteria for Medical Assistance as if living in their own homes, are entitled to General Medical and Surgical Services benefits.
A person living in or planning to enter an institution under private management is eligible for public assistance, provided the person meets all eligibility requirements in the same manner as a person not living in an institution (see Regulation 13 CSR 40-2.080(2).
Persons living in homes for the aged and infirm; in convalescent, nursing, shelter, lodging or boarding homes; or in private hospitals, operated commercially or by fraternal or religious groups, private welfare agencies, etc. may receive assistance. However, a claimant is not eligible to receive assistance in a private institution if one or more of the following conditions are met:
Note: This section does not apply to QMB, SLMB or QDWI
In determining the need of an applicant or recipient, it is essential that the standards used in measuring necessary expenses and the methods employed in computing income be the same for, and be equitably applied to all persons in similar circumstances. The basic or “standard” requirements include all items necessary to develop and maintain physical and mental health and the welfare and efficiency of children and adults.
In computing the income of an applicant or recipient, only those resources which are available during the period under consideration shall be taken into account, including those in kind as well as in cash.
If the income and resources of an applicant or recipient are sufficient to provide his requirements, the individual or assistance group would be considered self-sustaining and not eligible for assistance. If the income and resources are not sufficient to provide for the requirements of the individual or assistance group, the extent of need and the amount of grant for the applicant or recipient would then be determined.
As defined in Regulation 13 CSR 40-2.080(1), it is possible for a County Court or other public agency to classify a publicly owned institution as non-public or private. Public property that is under private control and management may be classified as a non-public or private facility.
When a County Court or other public agency leases a county home or similar institution to private persons, and recipients of public assistance are to be given care in the institution, send a copy of the lease and a report to the State Office. Indicate whether the institution is publicly or privately managed and controlled. Include information such as source of financial support, staff selection procedures, admission policies, operational control processes, etc. Based on the report information, the State Office determines whether the institution is public or private, and advises the local FSD office. Assistance payments may not be made to claimants residing in a leased County Home until the State Office determines the facility is not a public institution.
Changes in the lease (e.g., change of provisions in the lease, institution leased to a different lessor, etc.) or renewal of the lease requires submission of another report with a copy of the changed or renewed lease to the State Office.
The Missouri State Rehabilitation Center is certified as an acute care hospital with full Medicare/Medicaid participation. Therefore, an applicant for or recipient of assistance should be treated the same as an applicant or recipient entering a regular hospital.
This policy applies to any category of assistance for which the claimant is eligible when entering a hospital. Coverage is no longer restricted to indi-viduals 65 years of age and over.
All claimants admitted to the Missouri State Rehabilitation Center are required to submit to the 'means' test. Patients with coverage or potential cover-age by insurance, Medicare, Medicaid, other federal or State programs, worker's compensation, trusts, or estates are considered as able to pay. The 'means' test is not applied until all available sources are exhausted, at which time the Missouri State Rehabilitation Center applies the 'means' test to determine the patient's liability with respect to the uncovered portion of their bill. This practice allows the determination of medical expenses that can be charged against the applicant's spenddown amount, when applicable. The Missouri State Rehabilitation Center will provide verification of medical expenses incurred by the individual.
Out-of-state admissions remain the responsibility of the State of resi-dence, unless it can be established the individual intends to retain permanent residence in Missouri.
Lawrence County processes new applications when the individual is already in the Missouri State Rehabilitation Center, and is responsible for transferring the case to the appropriate county when the individual is released from the hospital.
An exception to this policy allows application processing for children and/or severely disabled individuals who are unable to complete the application process on their own behalf. Process applications in the county where the parent(s), guardians, or responsible person resides, if residing in a county other than Lawrence county.
Lawrence County staff will assist, as needed, in verifying information or in reporting known changes of circumstances, such as current hospital status, etc. Requests for these applications may originate from Missouri State Rehabilitation Center staff; parent(s), guardian, or responsible person(s); or Lawrence County FSD staff.