Complete a review of Supplemental Nursing Care (SNC) eligibility every 12 months. Every review or change in circumstances requires appropriate action and recording.
When one or more changes occur, evaluate which eligibility factors may be in question to determine whether a complete reinvestigation is necessary or whether a review of certain eligibility factors will suffice. This may include: marriage, appointment of guardian, change in living arrangements, or change in income.
Annual review requirements are the same as for the MO HealthNet for the Aged, Blind or Disabled (MHABD) program. Refer to Sections 0840.000.00 through 0840.015.05.
NOTE: When an active MO HealthNet/Supplemental Nursing Care participant changes to a vendor level of care or changes facilities, a reinvestigation is not required to complete the action. Make the appropriate changes to the case and if a reinvestigation is due, complete that as a separate action.
When MRT approves an SNC participant based on PTD eligibility requirements, medical re-determinations of the participant's certification for PTD should be begun so that the necessary medical and the Social Information Summary (IM-61) can be sent to the MRT at least two weeks before the date specified.
SNC participants are required to report changes in circumstances affecting eligibility factors within ten calendar days of the change. If the reported change in circumstances (address, income, resources, etc.) indicates a decrease in grant, lower level of care, or ineligibility, notify the participant of any action precipitated by the change within ten days of the date the participant reports the change.
If the change in circumstances results in an increase in grant, the increase becomes effective the month after the month in which the change is reported. If the increase is not reflected in the effective month's check, issue a deficiency payment.
Also issue deficiency payments to SNC participants when an underpayment of benefits has been made due to an error by the agency. Issue deficiency payments only on behalf of persons currently receiving assistance and only for the 12-month period preceding the month of discovery of the underpayments.
When it is necessary to reduce a participant's grant, the following applies:
When an active SNC participant enters a vendor nursing facility, (or moves to a MO HealthNet certified bed in a facility that has both vendor and non-vendor beds) refer to the policy in the Medical Assistance chapter for guidance in determining eligibility and transferring a case to vendor payments. Take action to stop the SNC cash grant, but continue MO HealthNet under SNC while vendor eligibility is being determined. Count any SNC payment the participant receives as income in the surplus computation.
EXAMPLE: An SNC participant receives a $200 SNC grant and $700 RSDI. He enters a MO HealthNet certified nursing facility on 9/23. The medical certification (DA-124) approving NF level of care is received 10/25. Since the November SNC payroll closing date has passed, the November SNC check should be pulled. The eligibility specialist would include the SNC check in the October surplus computation and base the November on-going surplus on the participant's RSDI.
If the Department of Health and Senior Services returns the Initial Assessment (DA-124) and indicates the participant is NOT medically certified:
NOTE: When an active MO HealthNet/Supplemental Nursing Care participant changes to a vendor level of care or changes facilities, a reinvestigation is not required to complete the action. Make the appropriate changes to the case and if a reinvestigation is due, complete that as a separate action.
A participant of any age is not eligible for the SNC cash grant while in a State Psychiatric Hospital (MHC).
When an active SNC participant, age 65 years or older, enters a State Psychiatric Hospital refer to the policy in the Medical Assistance chapter for guidance in determining eligibility and transferring a case to vendor payments. Take action to stop the SNC cash grant, but continue MO HealthNet under SNC while vendor eligibility is being determined. Count any SNC payment the participant receives as income in the surplus computation.
If the Department of Health and Senior Services returns the Initial Assessment (DA-124) and indicates the participant is NOT medically certified for the MHC level of care follow the procedures in Section 0630.020.05 to determine the participant's eligibility for non-vendor MO HealthNet.
When an active SNC participant under age 65 enters a State Psychiatric Hospital, take action to stop the SNC cash grant, but continue MO HealthNet under SNC while MHABD spend down/non-spend down eligibility is being determined.
NOTE: An advance notice of adverse action (IM-80) is not necessary to discontinue the SNC grant since the participant is entering an institution, where cash assistance may not be continued.
A participant of any age is not eligible for the SNC cash grant while in a public institution for the Intellectually Disabled (IMR).
When an active SNC participant enters an IMR refer to the policy in the Medical Assistance chapter for guidance in determining eligibility and transferring a case to vendor payments. Take action to stop the SNC cash grant, but continue MO HealthNet under SNC while vendor eligibility is being determined. Count any SNC payment the participant receives as income in the surplus computation.
NOTE: An advance notice of adverse action (IM-80) is not necessary since the participant is entering an institution, where cash assistance may not be continued.
A participant of any age is not eligible for the SNC cash grant while in the Missouri State Rehabilitation Center.
When an active SNC participant enters the Missouri State Rehabilitation Center, take action to stop the SNC cash grant. Continue MO HealthNet under SNC and follow the procedures in Section 0630.020.05 to determine the participant's eligibility MHABD spenddown/non-spenddown and other categories of MO HealthNet.
NOTE: An advance notice of adverse action (IM-80) is not necessary since the participant is entering an institution, where cash assistance may not be continued.
Once an individual is determined eligible for MO HealthNet, eligibility must continue uninterrupted until the individual is determined ineligible for every category of MO HealthNet. A termination without a review for on-going eligibility is improper. Reviews for on-going eligibility must be conducted without the involvement of the participant, if possible. This is known as an ex-parte review.
If a change in circumstances results in a determination of ineligibility for SNC, ineligibility for all MO HealthNet categories must be established prior to taking action to close the case. All available information must be carefully reviewed. If potential eligibility exists under another category, change the case address if necessary, and continue MO HealthNet under SNC while exploring the other eligibility. Action may be taken to discontinue the cash grant while not affecting the MO HealthNet eligibility.
Do not ask the participant to provide new information that is available to the agency or to re-verify current case information. In some situations it may be necessary to obtain additional information from the participant to determine eligibility in another category. Do not close while attempting to complete the new eligibility determination.
If the participant is determined eligible under another category, switch the individual to the appropriate category (an IM-1 is not necessary). Process both closing and approval transactions on the same day in order to prevent any disruption in healthcare coverage.
If the category the participant is eligible is MHABD spenddown send an advance notice of adverse action (IM-80) notifying the participant they will become spenddown the month after the IM-80 expires. After the IM-80 expires, register an MHABD spenddown application and:
If no other eligibility exists, initiate action to close the case by sending an advance notice of adverse action (IM-80). If a hearing is not requested close the active SNC case once the IM-80 expires and notify the participant in writing (IM-33) confirming the closing.