H-7300, Medicaid Coverage Issues Related to Nursing Facility Costs

Revision 12-3; Effective September 1, 2012

  • Community Attendant Services (CAS) (ME-Community Attendant) coverage, provides Medicaid payment for attendant care only. This coverage does not provide for nursing facility (NF) vendor payment, doctor visits, hospital stays, medically necessary items or prescription drug coverage.
  • Regular Medicaid coverage provides 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. Medicaid coverage provides for payment of prescription drug coverage, except when the person is dually eligible for both Medicare and Medicaid.
  • Qualified Medicare Beneficiary (MC-QMB) coverage indicates that Medicaid pays the Medicare premiums, deductibles and co-insurance, including Medicare-covered hospital and NF stays.

Examples:

Recipient 1 — When a person with only MC-QMB (also known as a Pure Q) enters a skilled nursing facility (SNF) from a hospital, Medicare will cover 100% of the SNF vendor costs for days 1-20. Medicare will cover 80% of the SNF vendor costs for days 21-100. As a Pure Q person, Medicaid's Q covers 100% 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-payment per day for days 21-100). As a Pure Q person, the person is not responsible for the amount of co-payment a Medicaid person must pay for nursing care.

Note: If the person does not remain a Pure Q recipient and becomes certified for full Medicaid, use the Recipient 2 example.

Recipient 2 — When a person living in the community enters an SNF from a hospital and is dually eligible for both Medicare and Medicaid (MQMB), Medicare will cover 100% of the SNF vendor costs for days 1-20. Even though the person is Medicaid 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 recipient is Medicaid eligible for vendor payment:

  • Make retroactive adjustments to ensure the correct benefits are reflected in the system of record if necessary.
  • The recipient will not be responsible for the remaining 20% of the SNF vendor costs (the Medicare co-payment per day for days 21-100).
  • The recipient will have a calculated Medicaid co-payment beginning day 21 and continuing.
  • Notify the recipient of the responsibility for the Medicaid co-payment.

Recipient 3 — When a CAS recipient (ME-Community Attendant) recipient who has Medicare but not MC-QMB 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 recipient’s Medicaid eligibility in an NF 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 recipient is Medicaid-eligible for vendor payment:

  • Make retroactive adjustments to ensure the correct benefits are reflected in the system of record if necessary.
  • The recipient will not be responsible for the remaining 20% of the SNF vendor costs (the Medicare co-payment per day for days 21-100).
  • The recipient will have a calculated Medicaid-co-payment beginning day 21 and continuing.
  • Notify the recipient of the responsibility for the Medicaid-co-payment.

If the person is not Medicaid-eligible for vendor payment and is not eligible for Pure Q, use the chart in Section H-7200, Medicare-Related Financial Responsibilities for Skilled Nursing Facility Care. Deny the person and send the appropriate denial notice. There will not be a calculated Medicaid-co-payment.

Recipient 4 — When a CAS (ME-Community Attendant) recipient with Qualified Medicare Beneficiary (MC-QMB) only 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 recipient's Medicaid eligibility in an NF 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 recipient is Medicaid eligible for vendor payment:

  • Make retroactive adjustments to ensure the correct benefits are reflected in the system of record if necessary.
  • The recipient will not be responsible for the remaining 20% of the SNF vendor costs (the Medicare co-payment per day for days 21-100).
  • The recipient will have a calculated Medicaid-co-payment beginning day 21 and continuing.
  • Notify the recipient of the responsibility for the Medicaid-co-payment.

If the person is not Medicaid eligible for vendor payment but is eligible for Pure Q, notify the recipient and use the Recipient 1 example.