GIS 16 MA/014 - Restriction/Exception Code N9 - Pending NH Eligibility Determination

The purpose of this General Information System (GIS) message is to inform Local Departments of Social Services (LDSSs) of a new Restriction/Exception (R/E) code for Medicaid recipients in permanent status in a nursing home pending a Medicaid eligibility determination for coverage of long term nursing home care. The new code, "N9 - Pending NH eligibility", will prevent a current FFS recipient from being enrolled in a managed care plan, and a current managed care enrollee from being transferred to another managed care plan, while an eligibility determination for Medicaid coverage of long term nursing home care is pending.

R/E code - "N9 - Pending NH eligibility" is available for data entry into eMedNY effective August 26, 2016. This code will replace the use of R/E code 90 "Managed Care Excluded" as indicated in 15 OHIP/ADM-01 "Transition of Long Term Nursing Home Benefit into Medicaid Managed Care" for Medicaid recipients permanently placed in a nursing home pending Medicaid permanent placement eligibility.

Effective immediately, LDSSs are instructed to data enter R/E code N9 into eMedNY when a nursing home provides appropriate documentation of permanent placement status, in conjunction with authorization by the plan if applicable, for a current Medicaid recipient to the LDSS. Districts [LDSS] are instructed to enter a begin date equal to the date of permanent placement, as indicated on form LDSS-3559 or its DOH approved local equivalent.

Once nursing home eligibility has been established, the local district will end date R/E code N9. If a FFS recipient is mandated to enroll in managed care, the local district will enter R/E N7 to start the process for outreach and enrollment into a managed care plan. If the recipient is currently enrolled in managed care, the local district will enter R/E N1-N6 as appropriate. The effective date of N1-N6 for a current managed care enrollee is the start date of permanent placement eligibility. As a reminder to the districts, any Nursing Home R/E code needs to be end dated if the recipient is discharged to a hospital or to the community. Please refer to 15 OHIP/ADM-01, "Transition of Long Term Nursing Home Benefit into Medicaid Managed Care, " for more information on Nursing Home R/E codes.

Please direct any questions to your Local District Support liaisons.