Marie Vitarelli & Kathy Bruni
Q: Please hire and additional person to assist Olga with W-10 reviews. This is a huge issue toward the timeliness of pay-starts and cans save time of Convalescent Unit workers, DSS caseworkers as well as facility business office managers.
A: We are in the process of hiring another nurse to be involved in the review of W-10s or their equivalent. The timeliness of the approval or denials would still depend upon the documentation received in this office and the response of the individual nursing facility to our REQUEST FOR INFORMATION inquiry.

Q: Is there a rules/reg book on MI/MR?
A: The Alternate Care Unit has a booklet of Guidelines and Procedures for PASRR. You can request a copy by contacting Diane Famiglietti at 860-424-5236. The statues are in Section 17b-359-360 and 17b-342 of the CT General Statutes. The federal regulations can be found in 42 CFR Ch 4, Section483.100-483.138.

Q: RE: MI/MR - where does active addiction get addressed? IE: Patient comes in for a medical stay but has an Etoh dependency. Often hospitals send people w/o correct DX on MI/MR - ie: patient comes in on January w/o DX and returns 3 months later with another DX when the appropriate measure to have MI/MR corrected. Why doesn't the MI/MR use DSM codes?
A: Addictions are not specifically addressed in the federal OBRA regulations. The codes used are those specified in the regulations. If you have a patient and the MI/MR information is incorrect, follow the change in condition requirements that is - if identified within the first 14 days of admission, contact the Alternate Care Unit. If identified 15 days or later, contact Advanced Behavioral Health, which is DMHAS's subcontractor.

Q: Can all letters requesting additional information for W-10 approvals be sent to the attention of the Business Office instead of the Administrator? (This will be more efficient as there will be a more prompt response.)
A: REQUEST FOR INFORMATION inquiries were sent to the business offices in the past but we were asked to submit them to the Administrators as the information requested was often clinical in nature and the business office did not forward them to the correct department in the facility.

Q: How do we address W10 forms that arrive with patients that are very incomplete? Is there any way to hold the hospital accountable?
A: Section 17b-262-707 of the Regulations of Connecticut State Agencies addresses the payment for admissions to nursing facility and the responsibility of the nursing facility. This regulation does not address the responsibilities of any referring entity.

Q: Does the W10 get sent to your office for every admission or only when someone will become eligible for T19?
A: W-10s or their equivalent must be sent to our office for every Medicaid admission or when a Medicaid application is generated while the client is in a nursing facility.

Q: What does PASARR stand for?
A: PASRR stands for Preadmission Screening Resident Review.

Steve Greenslade
Q: How do we get claims paid with Medicare HMO?
A: You would bill Medicare HMO the same as you do traditional Med A.

Q: When will 16 replace 96?
A: We are not sure if code 16 is actually replacing 96. To date DSS has not received any notification of this.

Q: When more than one reason applies - ie: benefits exhausted AND no 3 day stay, Is one reason better accepted than another?
A: No, both are technical denials so we look at them as the same .

Q: Level of care denials must be processed as a demand bill - do we need to do this or does the state process it this way?
A: DSS appeals level of care denials so they must be processed as a demand bill or they are returned by CMS as unable to appeal.

Q: Why does it state at the bottom of the 2nd page of the matrix: Note: Level of Care Denials (Code 16 and 96) must be processed as a demand bill?
A: In order for DSS to appeal, claims must be billed as a demand bill.

Q: When a resident is admitted from an assisted living facility, is this considered from home or from and institution, therefore not requiring a Medicare remittance?
A: This is considered an admission from the community, therefore you would be required to bill Medicare 1st.

Q: RE: Facility Denials (Benefits Period Exhausted) - Does it have to be signed or does a certified mail receipt (signed by the recipient of mail) suffice? If not - why?
A: DSS goes by Medicare guidelines.

Bob Augeri
Q: For Applied Income: When we have a resident that expires like on the 3rd of the month that applied income which is a Social Security Check or pension, is always returned since the person expired. When we bill we bill for 3 days because we do not get paid because the applied income is being deducted.
A: You shouldn't have to return the Social Security check you receive during the month the person dies because that check represents payment for the previous month. The only time you would need to return part of the check to the person's family is if the cost of care during the month of the person's death (based on the number of days the person was alive and receiving care) is less than the person's applied income. You should be able to keep that part of the applied income that does not exceed the cost of care for that month.

Q: RE: The Morenz Act - Are these exemptions increasing in numbers as Elder Care Lawyers become aware? Will this loophole be addressed by future regulation?
A: Yes, these exemptions are increasing. We are trying to amend the CT Statutes to allow us to recover assets from the community spouse. This may discourage couples from using this loophole.

Q: RE: Hardship cases - Are there particular forms needed for nursing homes to apply for Hardship for a resident?
A: No particular form is necessary, but you must have the resident's or his or her conservator's approval to request the hardship classification.

Q: If an Insurance policy face value is $1000 and the cash surrender is $2000, does this insurance policy need to be surrendered?
A: No. If the total face value of the person's life insurance policies is $1500 or less, we don't count the cash value of the policy as an asset. Even if the face value exceeds $1500, the person could take a loan against the policy to reduce the cash surrender value.

Q: Does Asset include home?
A: Not if the person is living there or is in a nursing home but expected to return home within six months. Also, if the person's spouse, disabled child, minor child or sibling (if the sibling has an equity interest in the home) is living there, the house is not considered an asset. If the person is in a nursing home and not expected to return home, and none of the other individuals listed above are living there, the person must be making a bona fide effort to sell the home. Otherwise, we would count the equity as an asset (the asset limit is $1600 for a single person). If the person's equity in the home exceeds $750,000, we will not pay for his or her nursing home care (based on the Deficit Reduction Act).

Q: A/I - are the months of admission and discharge excluded? ie: admit 5/1/07 - full A/I is due 5/31/07? Discharged 5/1/07 - full A/I due? A/I for short terms stays more than 30, less than 60 - how much of the income is excluded to pay for community shelter?
A: AI is due in the month in which the 30th consecutive day of institutionalization occurs. If the person is expected to return home within sixty days, we could allow $460 per month to be diverted for maintenance of the home ($250 per month if the person is not living alone). The diversion is not allowed for married persons, but there is a community spouse allowance if the person has a community spouse.

Q: In the past years, the life insurance policy that was not cashed in prior to granting would not be considered when determining if resident was over assets. The policy was simply cashed in and applied toward the current month. Why did they change this and can we go back to the old way?
A: The feds have told us that the person is ineligible if his or her assets exceed the limit. If we tried to go back to the old way and were audited by the feds, they would find us in error and we would be sanctioned.

Q: $8646 is used to determine penalty period. It costs >$10,000/mo to stay in nursing home. Even if we could retrieve 100% of the transferred asset, there is still an amount outstanding above the $8646 plus other medical expenses. How does the State plan on making the nursing home whole? From a social services standpoint, if a potential resident transferred assets and the now savvy nursing homes will not accept the resident due to the difficulty of collection - who will take care of the person?
A: We are unsure how to answer these questions because we really haven't had to deal with these situations prior to the implementation of the Deficit Reduction Act (DRA). Hopefully, the DRA will discourage people from making improper transfers to avoid jeopardizing Medicaid eligibility.

Q: Please explain the Morenz Decision?
A: When we determine the Medicaid eligibility of the institutionalized spouse (IS), we consider the assets of both the IS and the CS (community spouse). If the CS has more assets than are allowed, the excess is deemed available to the IS, and Medicaid will be denied. Under the Morenz decision, if the IS assigns his or her spousal support rights to us, we cannot consider the assets of the CS in determining the IS' eligibility.

Q: Can the Personal needs allowance, CSA Rates and MMNA rates all be changed in January each year instead of July and throughout the year?
A: The PNA changes in July per CT Statute. The other figures and the effective dates of their updates are based on federal rules. Some figures change in January, some in July. It would be nice if they all changed at the same time, but we don't have control over that.

Q: Does the married spouse rules also pertain to the civil unions?
A: No. The feds don't recognize civil unions, and Medicaid is a federal program.

Q: Over assets - Has there ever been or will there be a consideration as to if a client is over assets only because they neglected to pay A/I during the month that they NOT be considered over assets? Many times families do not want to pay A/I until the grant is determined by the caseworker. This causes over assets and subsequent diversions is large and A/I is small - it can take many months or years to pay off diversion.
A: You should try to collect the AI so that the person's assets do not exceed the limit. The only way we could grant a case for those pending months is if the Deputy Commissioner issues an administrative exception. We are reluctant to do this because if the case is audited by the feds, we will be found in error and might be sanctioned.