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SOUTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES

MEDICAID POLICY AND PROCEDURES MANUAL CHAPTER 304 – Nursing Home, Home and Community-Based Services, and General Hospital Page 1 304.01

Introduction to Nursing Home, and Home and Community Based Services................................................................................5

304.02 304.02.01

Application Form.............................................................................6 SSI or Other Medicaid Beneficiaries Applying for Nursing Home or Home and Community Based Services........................................6 Requests for Additional Information..................................................8

304.02.02 304.03

Categorical Eligibility Criteria........................................................8

304.04

Non-Financial Eligibility Criteria..................................................10

304.05 304.05.01 304.05.01A 304.05.02 304.05.03

Financial Eligibility Criteria..........................................................10 Income.............................................................................................10 Budgeting DDSN Work Therapy Wages.........................................11 Resources.......................................................................................12 Homestead Property.......................................................................12

304.06 304.06.01 304.06.02 304.06.03 304.06.04 304.06.05 304.06.06 304.06.07

Level of Care..................................................................................14 Level of Care Certification...............................................................14 When a Level of Care is Required..................................................15 Client Status Document..................................................................17 Client Status Document From CLTC...............................................17 Client Status Document From DDSN..............................................19 Client Status Document for PACE..................................................20 Client Status Document for the Psychiatric Residential Treatment Facility (PRTF) Waiver...................................................22

304.07 304.07.01

Standard of Promptness..............................................................24 Arranging for Alternate Placement..................................................25

304.08

Transfer of Assets Prior to February 8, 2006.............................25

304.09 304.09.01 304.09.02 304.09.02A 304.09.02B 304.09.02C 304.09.02D 304.09.02E 304.09.02F 304.09.02G 304.09.02H 304.09.02I 304.09.03 304.09.04

Transfer of Assets on or after February 8, 2006........................25 Definitions that Apply to Transfer of Assets and Trusts..................25 Transfer of Assets for Less than Fair Market Value........................26 Effective Date of Transfer of Assets Policy.....................................27 Individuals Affected by Transfer of Assets Provisions.....................27 Look-Back Date/Period...................................................................28 Penalty Period – Important Points..................................................34 Transfers by a Spouse....................................................................35 Transfers of Jointly Held Assets......................................................35 Transfers and Lifetime Rights to Property......................................37 Transfer of Assets in Month of Receipt...........................................38 Transfer of Income..........................................................................38 Exceptions to the Penalty................................................................39 Waiver of Transfer Penalty Procedure and 30 Day Hold................42

Version Month: August 2020

SOUTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES

MEDICAID POLICY AND PROCEDURES MANUAL CHAPTER 304 – Nursing Home, Home and Community-Based Services, and General Hospital Page 2 304.09.05 Calculating the Penalty Period........................................................43 304.09.06 Notification of Penalty.....................................................................46 304.09.07 Medicaid Benefits during Penalty Period........................................46 304.09.08 Annuities..........................................................................................47 304.10

Obtaining Other Assets/Elective Share......................................47

304.11 304.11.01 304.11.02 304.11.03 304.11.04

Promissory Notes.........................................................................48 Actuarially Sound Notes..................................................................49 Transfer of Assets Related to Promissory Notes............................50 Default on Payments.......................................................................51 Forgiving Principal Portions of Promissory Notes...........................51

304.12 304.12.01 304.12.02 304.12.03

Annuities........................................................................................52 Periodic Payments..........................................................................52 Purpose of Annuity..........................................................................52 Transfer penalty..............................................................................54

304.13 304.13.01

Spousal Impoverishment Provisions..........................................55 Definitions........................................................................................55

304.14 304.14.01 304.14.02

Spousal Impoverishment and Resources..................................56 Separated Spouses.........................................................................58 Undue Hardship..............................................................................60

304.15

Budgeting Income and Resources Under Spousal Impoverishment Provisions.........................................................60 304.15.01 Eligibility..........................................................................................60 304.15.02 Post-Eligibility..................................................................................61 304.15.02A Income Allocation............................................................................61 304.15.02B Resource Allocation........................................................................66 304.15.02C Changes in Community Spouse’s Resources after Approval.........68 304.15.03 Prenuptial Agreement......................................................................68 304.15.04 Resource Assessment....................................................................68

304.16 304.16.01 304.16.02

30-Consecutive Day Requirement...............................................69 Effective Date of Eligibility...............................................................69 Moving from a Medical Facility to Home and Community Based Services...........................................................................................70

304.17

Permit Days....................................................................................70

304.18 304.18.01 304.18.02 304.18.03

Vendor Payment............................................................................70 Recurring Income Used to Determine Vendor Payment.................70 Protected Income............................................................................76 Medicaid Eligibility and Vendor Payment........................................78

304.19 304.19.01 304.19.02

Income Trust..................................................................................78 Who May Be Covered Under this Provision...................................78 Income Trust Requirements............................................................79

Version Month: August 2020

SOUTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES

MEDICAID POLICY AND PROCEDURES MANUAL CHAPTER 304 – Nursing Home, Home and Community-Based Services, and General Hospital Page 3 304.19.03 Explanations and Forms to Give at Intake......................................79 304.19.04 Establishing an Income Trust..........................................................79 304.19.04A Who Can Sign the Trust Document?..............................................80 304.19.04B Review of the Income Trust............................................................80 304.19.04C Death of an Applicant......................................................................81 304.19.05 Funding the Income Trust...............................................................81 304.19.06 Income Eligibility.............................................................................84 304.19.07 Billing for Home and Community Based Services Waiver Program Participants.......................................................................96 304.19.08 Annual Accounting..........................................................................97 304.19.09 Trust Modification: Trustee or Bank Account Change.....................98 304.19.10 Non-Compliance with Terms of the Income Trust...........................98 304.19.11 Death of Income Trust Principal Beneficiary...................................99 304.19.12 Income Trust Dissolution.................................................................99 304.19.13 Income Trust and Transfer Penalties............................................100 304.19.14 Income Trust Identification/Set up Flow........................................101 304.20 304.20.01

Other Trusts.................................................................................103 Undue Hardships and Trusts........................................................103

304.21

Bed Hold Policy...........................................................................104

304.22

Medicare/Co-Insurance...............................................................106

304.23 304.23.01 304.23.02

DHHS Form 181 (Notice of Admission, Authorization and Change of Status for Long-Term Care).....................................106 Initiation of DHHS Form 181.........................................................107 Signature Requirements...............................................................107

304.24 304.24.01 304.24.02 304.24.03

Program for All-inclusive Care for the Elderly (PACE)............107 PACE Participant Enters a Nursing Home....................................107 PACE Participant Enters a Residential Care Facility....................108 PACE Participant Terminated from Program.................................109

304.25

Denial of Payment for New Admissions (DPNA).....................109

304.26 304.26.01 304.26.02

Miscellaneous Facts about Nursing Facilities.........................110 Private vs. Semi-Private Rooms...................................................110 Solicitation of Contributions from Medicaid Beneficiaries by Providers of Long-Term Care Services.........................................110 Sitters............................................................................................110 Condition of Admission..................................................................110 Continuing Care Retirement Communities (CCRCs)....................111

304.26.03 304.26.04 304.26.05 304.27

Estate Recovery...........................................................................111

304.28

Basic Application Process for Nursing Home and Home and Community Based Service Cases.............................................113

304.29

Case Record Requirements.......................................................116

Version Month: August 2020

SOUTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES

MEDICAID POLICY AND PROCEDURES MANUAL CHAPTER 304 – Nursing Home, Home and Community-Based Services, and General Hospital Page 4 304.30 Annual Review Procedures........................................................117 304.30.01 Nursing Home................................................................................117 304.30.02 Home and Community Based Services........................................118 304.31 304.31.01 304.31.02 304.31.03 304.31.04 304.31.05 304.31.06 304.31.06A 304.31.06B 304.31.06C 304.31.06D

Introduction to General Hospital...............................................119 General Hospital vs. Nursing Home Assistance...........................119 Non-Financial Eligibility Criteria....................................................120 Categorical Eligibility Criteria........................................................120 Financial Criteria...........................................................................121 Continued Eligibility.......................................................................121 Basic Application Process.............................................................122 Receipt of Application/Intake.........................................................122 Processing of Application..............................................................123 Determination of Eligibility/Ineligibility...........................................123 Continued Eligibility.......................................................................124

APPENDIX A

Life Expectancy Table.................................................................125

APPENDIX B

Non-Covered Medical Expenses and Allowable Deductions .......................................................................................................126

APPENDIX C

DHHS Form 181...........................................................................127

APPENDIX D

Current Average Monthly Nursing Facility and Medicaid Payment Rates............................................................................129

APPENDIX E

Comparison of Applicable Required Elements for Institutional Programs (NH-HCBS-GH).....................................133

APPENDIX F

Recurring Income (Cost of Care) Allowable Deductions – NH/HCBS Cases..........................................................................134

APPENDIX G

Home Equity Procedures Flowchart.........................................135

APPENDIX H

Waiver Programs Comparison Chart........................................136

APPENDIX I

Look-back Procedures for ABD Applicants.............................139

APPENDIX J

Phoenix Procedures...................................................................140

Version Month: August 2020

SOUTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES

MEDICAID POLICY AND PROCEDURES MANUAL CHAPTER 304 – Nursing Home, Home and Community-Based Services, and General Hospital Page 5

304.01

Introduction to Nursing Home, and Home and Community Based Services (Eff. 09/01/17)

The South Carolina Medicaid program sponsors the payment of long-term care for individuals who reside in certain licensed and certified medical facilities. Such facilities include:   

Skilled Nursing Facilities (SNF) and Intermediate Care Facilities (ICF) Swing Beds Intermediate Care Facilities for the Intellectually Disabled(ICF/ID)

The Medicaid program also pays for special services to individuals who participate in Home and Community Based Services (HCBS) waivers and a Program for All Inclusive Care of the Elderly (PACE). Refer to Appendix H for a comparison of the different waivers. Refer to Appendix H for a comparison of the different programs. These programs include: 



 

Community Long-Term Care o Community Choices (formerly known as Elderly and Disabled) o HIV/AIDS o Ventilator (VENT) Department of Disability and Special Needs o Head and Spinal Cord Injury (HASCI) o Intellectual Disability/Related Disabilities (ID/RD) Program of All Inclusive Care of the Elderly (PACE) Department of Mental Health o Psychiatric Residential Treatment Facility (PRTF)

This chapter includes policies and procedures used to determine Medicaid eligibility for institutionalized individuals. For Medicaid purposes, an institutionalized individual is one who resides in a medical institution (nursing home), or receives home and community based services. The same eligibility requirements apply to both the Nursing Home (NH) and the Home and Community Based Services (HCBS) programs. The difference is that individuals who need nursing home care but choose to stay at home rather than in an institution, can receive special services through a waiver to help them remain in their home. To qualify for the Medicaid coverage discussed in this chapter, an individual must meet categorical eligibility. Normally that means he must be aged, blind, or disabled. If the individual is eligible for full Medicaid benefits under another category that has different categorical eligibility requirements, he may still qualify for payment of Nursing Home or HCBS services if all other criteria discussed in this chapter are met and he remains Medicaid eligible. Version Month: August 2020

SOUTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES

MEDICAID POLICY AND PROCEDURES MANUAL CHAPTER 304 – Nursing Home, Home and Community-Based Services, and General Hospital Page 6 Most individuals who qualify for Medicaid sponsorship in a long-term facility must contribute toward the cost of care. Individuals who qualify for HCBS with an Income Trust may be required to contribute toward the cost of the services they receive. If an individual is not Medicaid eligible before he/she enters a medical institution or a waiver program, he/she must receive such services or a combination of such services for 30 consecutive days before he/she can be considered institutionalized. Table of Contents

304.02

Application Form (Eff. 10/01/13)

Generally, Form 3401, Application for Nursing Home, Residential or In-Home Care OR DHHS Form 3400, Healthy Connections Application, AND DHHS Form 3400-B, Additional Information for Nursing Home and In-Home Care, are used to obtain information needed to determine eligibility under the institutional categories. 304.02.01

SSI or Other Medicaid Beneficiaries Applying for Nursing Home or Home and Community Based Services (Rev. 08/01/19)

The DHHS Form 3401 OR the DHHS Form 3400 with the DHHS Form 3400-B are: 



NOT required when the SSI recipient: o Enters a nursing facility and the SSI payment is expected to continue o Enters a Home and Community Based Services waiver program Required when the SSI recipient: o Enters a nursing home and the SSI payment will not continue (such as a dual SSI/SSA recipient)

Supplemental Security Income Recipients  

 



SSI recipients who enter a facility and have their SSI benefits terminated will be required to file a Medicaid application. Dual eligibles (recipients of both Retirement, Survivors, and Disability Insurance (RSDI) and SSI benefits) who enter a facility permanently (more than 90 calendar days) and whose RSDI benefit is greater than $50 will usually have their SSI benefits terminated. Therefore, a Medicaid application will be required Dual eligibles entering a facility t...