TN 33 (07-11)

SI 00520.012 Payment Limit Due to Medicaid Transfer of Resources Penalty

Citations:

Social Security Act, Section 1611(e)(1)(B);

20 CFR 416.414

A. Policy on $30 payment limit due to Medicaid transfer of resources penalty

The $30 payment limit applies to a recipient who is a resident of a medical treatment facility during any period the recipient is ineligible for Medicaid payment of his institutional care because he has transferred resources for less than their fair market value under the Medicaid transfer of resources rules.

  • The recipient cannot get more than $30 in Federal SSI money plus any applicable state supplement because he or she is in a medical care facility, such as a hospital or nursing home; and

  • Medicaid would pay for his or her care except that he or she gave away a resource or sold it for less than it was worth.

B. Procedure on payment limit due to Medicaid transfer of resources penalty

1. Regional Office (RO) procedure for payment limit due to Medicaid transfer of resources penalty situations

  • Ensure the existence of procedures by which state Medicaid agencies can notify SSA when a recipient is ineligible for coverage of institutional services because of transfer of resources.

  • Ensure that all field offices are aware of the procedure(s) used for this purpose and report any pattern of discrepancies or inadequacies to central office.

NOTE: Local procedures may already be in place for providing information to SSA.

2. Field Office (FO) procedure for payment limit due to Medicaid transfer of resources penalty situations

  • For purposes of this provision, treat as conclusive a Medicaid agency notice that an recipient is not eligible for Medicaid payment for his institutional care because of a transfer of resources.

  • Document the recipient’s file by putting a copy of the state notification in the Non-Disability Repository for Evidentiary Documents (NDReD), or by completing a DROC screen. Documentation must specify the period for which the recipient is Medicaid ineligible because of a transfer of resources.

  • Assume, absent evidence to the contrary, that a recipient is not eligible for Medicaid payment for his institutional care because of a transfer of resources.

  • Report to your RO any pattern of discrepancies or inadequacies in the notification procedure.

3. Procedure for issuing manual notices about the $30 payment limit due to Medicaid transfer of resources penalty

Issue a manual notice when you impose the $30 payment limit because of a transfer of resources, including those cases where the payment limit is already in effect but the reason for imposing the payment limit has changed because of the transfer of a resource. Use the following language for the notice.

“You were in a hospital or other institution for (number of ) months.  Medicaid would have paid more than half the cost of your care if you did not have a penalty for an improper transfer of resources.”

NOTE: Follow the special notice procedures in NL 01001.010 if you will send the notice to a claimant, recipient, or representative payee who alleges being blind or visually impaired.

4. Procedure on systems input for $30 payment limit due to Medicaid transfer of resources penalty

Set a diary (see SM 01301.200) to indicate ineligibility for Medicaid covered nursing services due to a resource transfer.

If a state notifies the FO that an recipient has been found ineligible for Medicaid covered nursing services and you determine that the $30 payment limit applies, take the following steps.

  • Delete the MN diary code that we input per SI 01150.112.

    • Input the diary code MV along with the date provided by the state that the recipient may be eligible again.

    EXAMPLE: Code a period of ineligibility ending June 1, 2009 as MV060109.

C. References for $30 payment limit due to Medicaid transfer of resources penalty

  • SSI transfer of resources after July 1, 1988, SI 01150.012

  • Medicaid implications of a transfer of resources, SI 01730.046

  • Diary code and date (DA), SM 01301.200

  • Deletion of diaries, SM 01301.205

  • Update Diaries, MSOM BUSSR 002.019