ROLE OF THE COUNTY DEPARTMENT OF SOCIAL/HUMAN SERVICE STAFF IN NURSING
The County Department of Social/Human Services shall be
responsible for the following in all nursing facility placements involving
either clients of medical assistance or applicants for assistance:
A. The determination of existing or potential
eligibility for medical assistance.
B. The referral, whenever possible, of all
Medicaid eligible clients/applicants who are eligible for Medicare benefits to
facilities certified for participation in the Medicare Program.
In those instances in which an individual
residing in a nursing facility under some method of reimbursement other than
Medicaid makes application for medical assistance, the county must provide
notice of the application referral date to both the nursing facility and the
Utilization Review Contractor.
1. Such notice
must be provided verbally to both the facility and the Utilization Review
Contractor within two (2) working days of the application referral
2. Written notice must be
mailed to the facility within five (5) working days.
3. Such notice is critical to the timely
conduct of admission review by the Utilization Review Contractor.
In those instances where
eligibility is determined to be effective three months prior to the date of
application pursuant to Department rules and regulations, the County Department
of Social/Human Services shall notify the nursing facility of this circumstance
This should be written in the area reserved for comments in
Section VI(5) of the Form AP-5615. Similar verbal or written notice must be
given or mailed to the Utilization Review Contractor, utilizing a format as
determined by the Department.
The Form AP-5615 is intended as a method
for communicating the status of a resident or applicant, or actions which
change that status, between nursing facility, the County Department of
Social/Human Services, and the Department. Examples of such actions are
admission, discharge, readmission, death or changes in resident income. Failure
to complete the AP-5615, or to properly verify information reported thereon in
a timely fashion, results in inappropriate reimbursement to nursing facilities,
inequitable assistance payments, and the loss of documentation necessary for
Department field audit staff. Upon receipt of Form AP-5615, the County
Department of Social/Human Services shall be responsible for the following.
A. Verify, correct, and complete, when
necessary, the client/applicant's name, State ID number, and all other
client/applicant income. Such verification must occur on a regular basis. All
income of the client which is in excess of the amount reserved for personal
needs allowance, less earned income (if appropriate), less spousal and
dependent care allowance, and less home maintenance allowance, and less
allowable expenses for medical and remedial care (see PETI deductions as
defined in 10 CCR 2505-10 sections 8.100.7.T and 8.482.33), must be applied by
the client/applicant toward his/her care. Changes in income must be reflected
in submission of a new eligibility reporting form and a new AP-5615.
Verify client payment. This amount must be
calculated by per diem appropriately in all months for which Medicaid
reimbursement covers less than a full month's care.
1. Client payment may be waived and zero
(-0-) client payment applied only under the conditions as defined in 10 CCR
2505-10 section 8.482.34.D.1.
Client payment may not be waived (other than for the exceptions provided for in
10 CCR 2505-10 section 8.415.11.C.1), in the instances as defined in 10 CCR
2505-10 section 8.482.34.D.2.
When client payment is calculated by per diem, the amount shown on the AP-5615
will be that amount to be paid by the resident, rather than the amount to be
calculated by per diem calculation.
4. Corrections to income or client payment
shall be initialed and dated by the income maintenance technician from the
County Department of Social/Human Services.
D. Review the date of action, such as
admission, readmission, discharge, death, or change in client payment being
reported and verify as necessary;
Indicate approval or denial of action being reported and effective date of that
approval or denial; and
F. Sign and
date all copies, and distribute in accordance with instructions on the reverse
side of page three of the AP-5615 form.