Special Situations - Assigning Excess Resources to Medical Institutions

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Revised April 18, 2012

Applicants and Assignment of Excess When Medicare Pays 100%

A client is not eligible if they have excess resources that must be assigned toward cost of care (medical institution) when there is no obligation to pay the facility for that month because Medicare or another TPL source is covering 100% of the cost. Deny eligibility for that month as there isn't a cost of care the client is obligated to pay. Consider eligibility for the following month.

NOTE:

This is only for issues where the client has excess resources and other coverage. If the client doesn't have excess resources, Medicare or other TPL coverage does not affect eligibility.

EXAMPLE

Example #1 Excess, Not Eligible:

Arlo is single and his monthly income is $2,000. On 2/1 his resources were $2500 after reducing for out of pocket medical expenses. He admits to the nursing home under Medicare on 2/19 and applies for Medicaid. Medicare is paying the cost at $100%. Because he has no obligation toward his cost of care, his excess resources cannot be assigned to an actual medical obligation. He is not resource eligible . Deny February for being over resources and consider eligibility for March.

EXAMPLE

Example #2. Excess, Is eligible:

Milly is single and her monthly income is $2,000. On 2/1 her resources were $2,000 after reducing for out of pocket medical expenses. She enters the nursing home under Medicare on 2/19 and applies for Medicaid. Medicare is paying the cost at 100%. She is eligible because her resources do not need to be assigned toward the cost of care.

For months where there is other coverage for only a part of a month, eligibility with excess resources will be based on the coast for the number of days the client is obligated to pay, similar to a partial month with excess resources:

If the assigned excess plus income is greater than the cost for the number of days of client obligation, the client isn't eligible.
If the assigned excess plus income is no greater than the cost for the number of days of client obligation, the client is eligible and must pay the excess toward care.
Code the date the client starts having an obligation to pay as the payment authorization date.

Active Cases and Excess Resources

If excess resources were assigned but never paid and the client is still over resources in a subsequent month, you cannot assign the same excess again. The only alternative is to terminate the case.

Determine if the excess is the same funds previously assigned
If it is the same funds, do not assign them again
Find out if they have paid but it is not yet reflected in the accounts by discussing with the institution bookkeeper
If it has not been paid, advise the client they are not eligible as their eligibility was contingent upon them paying that excess toward care
Determine if/when they are going to pay it and follow up
If client fails to pay it after allowing a reasonable time (10 days) propose termination

Advise HQ there is a situation where an active medical institution case starts receiving Medicare coverage at 100% (nursing home readmit after a hospital stay) AND has excess resources. This will be very rare and most likely will be an overpayment.