Institutional Care FAQs
How does my relative get Medicaid Nursing Home Care?
An individual must meet both financial and medical eligibility to qualify for nursing home care.
Financial eligibility for Institutional Medicaid is determined by the Income Support Division Office in the person's county of residence. Eligibility for Supplemental Security Income (SSI) is determined at the Social Security Administration. Individuals receiving SSI are eligible for Medicaid benefits, including nursing home care.
Medical eligibility is determined by Medicaid's Utilization Review Contractor. There must be a doctor's order recommending nursing home care. The doctor must also recommend a specific level of care, that is, High Nursing Facility care (HNF) or Low Nursing Facility care (LNF). The nursing home submits the doctor's order and supporting documentation, along with a Long Term Care Abstract form, to the UR contractor. The UR contractor compares the information sent by the nursing home against Medicaid's medical criteria. If the documentation sent by the nursing home meets the medical criteria, the UR contractor will approve a certain number of days.
With both financial and medical eligibility approval, Medicaid will pay for all or part of a person's nursing home care for the approved period.
How does a permanent nursing facility (NF) patient who is supposed to be Medicaid FFS get enrolled in Medicaid Salud!, a managed care program?
This situation will occur with people who are on Supplemental Security Income (SSI).
The most common situation which results in a NF fee-for-service patient being enrolled in Salud! occurs when an initial abstract or a continued stay abstract needs to be submitted to the Medicaid Utilization Review contractor in order to start or continue medical eligibility.
The NF sends the abstract for review. The UR contractor reviews the abstract and the abstract is not approved (submitted late or returned for more information) prior to expiration of previous abstract. The NF works with the UR contractor to get the abstract approved. In the meantime, the previous abstract expires.
During the period in which the previous abstract expired and a new abstract is not approved, the Medicaid Management Information System (MMIS) has searched the data system for individuals who should be on Salud!. When the search component reaches the long term care screen, where abstract information is stored, and sees there is not a current abstract on file, the system will assume that person is no longer in a NF and will automatically enroll the person in Salud!
How does a permanent nursing home patient get disenrolled from Salud! Medicaid Managed Care and back to fee-for-service Medicaid?
Follow the steps below.
- The nursing facility (NF) should determine the dates of service (DOS) for which the resident must be disenrolled from Salud!.
- The NF should then check the resident’s file at the facility to determine what other providers, if any, rendered services to the resident during the DOS. (See item "a" above)
- If the resident did receive services from other providers, the NF should contact those providers to determine:
- whether the provider billed Salud! during the relevant DOS, and
- whether the provider was paid by Salud!.
- Disenrollment can occur if the other provider(s) have not been paid by Salud!. The NF should explain the situation and ask the provider(s) to delay billing until the resident in question has been disenrolled from Salud! and returned to fee-for-service Medicaid.
- The NF should fax a short statement with the following information to HSD Medical Assistance Division, 505-827-3185:
- resident’s name and Social Security number clearly identified;
- DOS for which disenrollment from Salud! needs to occur;
- a statement certifying that the provider(s) as determined in items "b" and "c" above, were not paid by Salud! for DOS;
- a copy of the approved abstract which is inclusive of the DOS in question.
- The NF can bill fee-for-service Medicaid after the Medical Assistance Division disenrolls the resident from Salud!.
- The NF should contact the other provider(s) to let them know the situation has been resolved and they can bill fee-for-service Medicaid.
Medical Assistance Division cannot disenroll the resident from Salud! for the month for which any services were paid by Salud!.
The NF cannot bill fee-for-service Medicaid if other providers have been paid by Salud! during the DOS in question.
The longer the NF waits to follow up on a situation where a resident was enrolled in Salud!, the more likely services will have been paid for by Salud! for a resident and disenrollment cannot occur.