In order for KEES to correctly change spenddowns and/or patient liability amounts for Long Term Care changes, there are specific steps to follow depending on the situation. It is important to note, for Long Term Care (LTC) programs, the consumer receiving LTC must be the only person in the program block for the EDBC rules to work correctly. If there are any other persons in the program block the EDBC calculation will not appropriately process some types of LTC benefits. See Add New Program or Reapply Program if needed.
Discontinuing a Temporary Stay - Existing/Continuing Medical Program
Changing an Institutional Care Temporary Stay to a Permanent Stay
HCBS to Institutional Care - Temporary Stay to Permanent Stay
HCBS to Independent Living - Existing/Continuing Medical Program
Institutional Care to Institutional Care – Change in Facility
Shortening a Base Period When Changing Coverage to a Different Program Type
PACE to Institutional Care – Temporary Stay to Permanent Stay Out of Network
Working Healthy (with or without WORK) to Institutional Care – Permanent Stay
Working Healthy (with or without WORK) to Institutional Care - Temporary Stay
When an individual is being processed for Long Term Care (LTC), the aid code should be 300/XX if the consumer's income is under 300% of the SSI limit on income.
If the consumer's income is in excess of the 300% figure but is less than the cost of care, the consumer receives an MN3/XX aid code on the EDBC Summary. KEES will do this automatically if all necessary data is entered, especially actual cost of care.
If the consumer is over the 300% figure and the patient liability exceeds the cost of care, the individual is not eligible for LTC payment. In this case, a regular Medically Needy determination should be completed by removing the LTC Data and changing the RMT from LTC to Medical. This will establish a 6 month base period. Facility costs may be allowed against the spenddown by entering the information on the Expense page in KEES.
300/OA/N/N which translates to 300% of SSI Standard – Aged/Not Sobra/Not Inmate
Title 19 aid codes are required for LTC. See Medical Aid Codes for more information.
A consumer must have a Title 19 aid code for MMIS. When the user processes a case for Long Term Care the aid code is 300/XX if the consumer is under the 300% of the SSI limit on income. For 2015, this is $2199.00 in monthly income. If the Consumer's income is in excess of $2199.00 per month the consumer receives an MDN/XX aid code on the EDBC Summary. This aid code MUST be changed to the 300/XX aid code using the Medical Summary Override in order for benefits to be sent to the MMIS. Select the appropriate Medically Needy - below SSI Standard or Medically Needy - below SSI Standard Cost Share depending on the consumer's population (Aged, Blind, Child, or Disabled) and liability determination. Coding changes must take place in the MMIS for it to be able to accept the MDN/XX aid code AND the LTC eligibility together.
Click the Override Medical Summary button to navigate to the Override List page.
Click the Override button for the Medically Needy budget to go to the Override Detail page.
Select the correct Medically Needy – XXXX below SSI Standard Cost Share (most of the time this is the “Aged” category, but could be “Disabled”).
Remove the comma from the Patient Liability amount, if necessary.
Set a Start Date of the first day of the EDBC month using the <mm/dd/yyyy> format or the calendar icon.
Set an End Date the last day of the EDBC month (essentially a one month base) using the <mm/dd/yyyy> format or the calendar icon.
Click the Save and Continue button to leave the Detail and return to the List page.
Select the Override Reason of Administrative Decision on the List page.
Click the Save and Return button to return to the Medical EDBC Summary page.
Click the Accept and Save button if the Medical EDBC Summary looks correct (has 300 aid code, correct patient liability, and LTC details).