SEQUENCING OF MA-LTC ONLINE COURSES

Transcription

1 SEQUENCING OF MA-LTC ONLINE COURSES The MA payment of LTC services (MA-LTC) courses are designed to build on MA-LTC policy information and policies from one course to another. Courses are listed in the recommended sequence of completion. Introduction to LTCFs and Waivers Provides a high-level introduction to MA-LTC as applied to people receiving services through one of five home and community-based waiver programs or people residing in a long-term care facility (LTCF). The course introduces the five training cases that will be used throughout the LTC course sequencing. MA-LTC Basics Reviews MA eligibility requirements as applied to a person requesting MA- LTC and introduces the forms used to request MA-LTC. This course also introduces the concept of the community spouse, the institutional level of care requirement and the Home Equity Limit. Prerequisite: Introduction to LTC and Waivers. Asset Assessment Examines how to determine asset eligibility for certain people requesting MA-LTC that need an asset assessment. It provides instruction for: Using asset assessment forms. Evaluating assets based on asset assessment rules. Completing requested and required asset assessments. Prerequisites: MA-LTC Basics, Annuities 101 and Advanced Assets. Annuities and MA-LTC Introduces you to the MA-LTC eligibility requirements applied to annuities, including: Designating DHS as the preferred remainder beneficiary. Determining if a period of ineligibility must be applied. Prerequisites: MA-LTC Basics, Advanced Assets, Annuities 101 and Asset Assessment. MA-LTC Transfers Provides an in-depth discussion of income and asset transfer policy as applied to MA-LTC, including: Determining the uncompensated transfer amount. Calculating a transfer penalty period. Applying the transfer penalty. Introduction to LTCFs and Waivers 1 Rev. 03/21/13 Health Care Training

2 SEQUENCING OF MA-LTC ONLINE COURSES Prerequisite: Annuities and MA-LTC. Long-Term Care Partnership Provides MA-LTC policy requirements for a person who is requesting MA- LTC and is enrolled in a long-term care (LTC) insurance policy. Topics covered include: Determining if the policy is qualified as a Partnership policy. Protecting assets. Evaluating protected assets. Prerequisite: MA-LTC Basics. Income and MA-LTC Provides an in-depth look at the process for determining the client s obligation toward his or her cost of care. Topics include: Using different types of income calculations. Deductions, disregards and allowances available with each type of income calculation. Prerequisite: MA-LTC Basics. MA-LTC Spenddowns and Waiver Obligations Provides an in-depth look at an MA-LTC client s obligation toward his or her cost of care, including a medical spenddown, an LTC spenddown, a waiver obligation or a combination LTC/medical spenddown. Prerequisite: Income and MA-LTC Service Delivery for MA-LTC Compares how payment of LTC services differs when an MA-LTC enrollee receives services through fee-for-service versus managed care. It also introduces you to managed care products, such as MSHO, SNBC and MSC +. Prerequisites: Income and MA-LTC. LTC Training Caseload Summary Reviews each of the LTC training cases processed throughout the MA- LTC online training courses sequence. It also provides suggestions to help organize training materials for use during MA-LTC Systems. Prerequisites: All MA-LTC online courses (listed above). Introduction to LTCFs and Waivers 2 Rev. 03/21/13 Health Care Training

3 INTRODUCTION TO LTCFS AND WAIVERS COURSE OBJECTIVES Long-Term Care Facilities Identify the types of facilities that are LTCFs. Recall at least five LTC services provided for clients residing in an LTCF. List eligibility criteria for MA-LTC services for people residing in an LTCF. Home and Community-Based Services Waiver Programs Describe the purpose of each of the home and community-based services waiver programs and the Alternative Care (AC) program. List at least five services provided to clients receiving services through each of the programs. List eligibility criteria for MA-LTC for each of the home and communitybased services waiver programs. Introduction to LTCFs and Waivers 3 Rev. 03/21/13 - Health Care Training

4 MA-LTC COMMUNITY RESOURCES Below is a list of community resources available for clients in need of LTC services and their families. Disability Minnesota Disability Linkage Line Office of Ombudsman for Long-Term Care Select Aging Minnesota Board on Aging MinnesotaHelp.info Minnesota RXconnect Metropolitan Area Agency on Aging Minnesota Department of Veteran Affairs or LinkVet Senior Linkage Line Introduction to LTCFs and Waivers 4 Rev. 03/21/13 Health Care Training

5 LTC TRAINING CASELOAD Case Name Emily Anderson Padma Das Sinclair Jefferson Andreas Malone Isabella Springer MA-LTC Request Reason LTCF resident Elderly Waiver Disability Waiver LTCF resident DD Waiver Case Information Age 89. Admitted to Bethany Care Center after a hospitalization. Enrolled in Medicare Parts A, B & D. Daughter lived with her prior to placement. Age 76. Hospitalized last month. Lives with her husband. Enrolled in Medicare Parts A, B & D LTCC indicates the need for an institutional level of care. Age 58. Receives RSDI, disability. LTCC indicates the need for institutional level of care. Wants to continue to live with his wife and grandson. Age 78. Current MA/QMB enrollee. Admitted to Lyngblomsten Care Center. Receives SSI due to age. Enrolled in Medicare Parts A, B & D. Prior to LTCF placement rented from niece and her family. Age 4. Disabled since birth. Full team screening determined she needs an ICF/DD level of care. Lives with parents and older brother. Introduction to LTCFs and Waivers 5 Rev. 03/21/13 - Health Care Training

6 LTCF CRITERIA What is an LTCF? A long-term care facility includes stays in any of the following: A skilled nursing facility (SNF). A medical hospital, but only when the person receives skilled nursing services while hospitalized. An Intermediate Care Facility for a person with Developmental Disabilities (ICF/DD). People residing in a non-medicaid-certified facility are considered to be residing in the community. Covered Services MA-LTC covered services for a person residing in an LTCF are: MA-covered services. Skilled nursing facility care. Nursing facility care in an inpatient medical hospital. Nursing facility care in an ICF or ICF/DD. MA-LTC Eligibility Requirements The eligibility requirements that must be met to be eligible for MA-LTC are: Meet all MA eligibility requirements (including an asset assessment as required). Require an institutional level of care as confirmed by a Pre-Admission Screening. Have a home equity of $543,000 or less (unless exempt). Name DHS as a preferred remainder beneficiary on certain annuities. Not be subject to a transfer penalty. Introduction to LTCFs and Waivers 6 Rev. 12/10/13- Health Care Training

7 EW CRITERIA What is the Elderly Waiver? The purpose of the Elderly Waiver program, administered by the Department of Human Services (DHS), is to provide funding for home and community-based services for people age 65 and over. People requesting Elderly Waiver services require a SNF level of care. Covered Services Examples of covered services include: Basic MA covered services. Elderly Waiver Services, including but not limited to: o Adult day care. o Adult foster care. o Case management. o Chore services. o Companion services. o Extended home health care. o Home-delivered meals. o Homemaker services. o Transitional services. MA-LTC Eligibility Requirements MA-LTC eligibility requirements for the Elderly Waiver are: Be age 65 and over. Meet all MA eligibility requirements (including an asset assessment as required). Require an institutional level of care as determined by a long-term care consultation (LTCC) completed within the past 60 calendar days which indicates that services are anticipated to begin within the next 30 days. Have a home equity of $543,000 or less (unless exempt). Name DHS as a preferred remainder beneficiary on certain annuities. Not be subject to a transfer penalty. Introduction to LTCFs and Waivers 7 Rev. 12/10/13- Health Care Training

8 EW VS. AC Is client s total monthly income greater than the Special Income Standard (SIS)? Yes Does the client have a spouse? No No Yes Client may choose between AC and EW. Note: If AC is chosen, they may have MA eligibility with the spenddown concurrently. No Does the spouse receive services through EW/AC or reside in a long-term care facility? Yes Client must receive services through EW. Is client s total monthly income greater than 120% FPG? No Yes Client may choose between AC and EW. Note: If AC is chosen, they are not eligible for MA with a spenddown. Client must receive services through EW. Note: The client may receive services through AC for up to 60 days while MA is pending. Introduction to LTCFs and Waivers 8 Rev. 03/18/13 - Health Care Training

9 CAC CRITERIA What is the CAC Waiver? The purpose of the Community Alternative Care (CAC) program, administered by the DHS Disability Services Division, is funding home and community-based services for chronically ill or medically fragile children and adults. People requesting the CAC Waiver require a hospital level of care. Covered Services Examples of covered services include: Basic MA covered services. CAC covered services, including but not limited to: o Case management. o Environmental adaptations and modifications. o Foster care. o Homemaker services. o Respite care. o Extended coverage for certain basic MA covered services. Transitional Services. MA-LTC Eligibility Requirements MA-LTC eligibility requirements for the CAC waiver are: Be under age 65. Be certified disabled by SSA or SMRT. Meet all MA eligibility requirements. Require an institutional level of care as determined by a long-term care consultation (LTCC) completed within the past 60 calendar days which indicates that services are anticipated to begin within the next 30 days. Have a home equity of $543,000 or less (unless exempt). Name DHS as a preferred remainder beneficiary on certain annuities. Not be subject to a transfer penalty. Introduction to LTCFs and Waivers 10 Rev.12/10/13 Health Care Training

10 CADI CRITERIA What is the CADI Waiver? The purpose of the Community Alternatives for Disabled Individuals (CADI) program, administered by the DHS Disability Services Division, is funding home and community-based services for children and adults. People requesting the CADI waiver require a nursing facility level of care. Covered Services Examples of covered services include: Basic MA covered services. CADI covered services including but not limited to: o Adult day care. o Respite care. o Homemaker services. o Adaptations to the person s home or vehicle. o Extended home health services. o Case management. o Assisted living. MA-LTC Eligibility Requirements MA-LTC eligibility requirements for the CADI waiver are: Be under age 65. Be certified disabled by SSA or SMRT. Meet all MA eligibility requirements. Require an institutional level of care as determined by a long-term care consultation (LTCC) completed within the past 60 calendar days which indicates that services are anticipated to begin within the next 30 days. Have a home equity of $543,000 or less (unless exempt). Name DHS as a preferred remainder beneficiary on certain annuities. Not be subject to a transfer penalty. Introduction to LTCFs and Waivers 11 Rev.12/10/13 Health Care Training

11 BI CRITERIA What is the BI Waiver? The purpose of the Brain Injury (BI) (formerly TBI Traumatic Brain Injury) program, administered by the DHS Disability Services Division, is funding home and community-based services for children and adults who have an acquired or degenerative brain injury. People requesting the BI waiver require an institutional or neurobehavioral hospital level of care. Covered Services Examples of covered services include: Basic MA covered services. BI covered services including but not limited to: o Case management. o Assisted living. o Behavior programming. o Chore services. o Family counseling and training. o Home delivered meals. o Independent living skills counseling, maintenance and therapies. Transitional services. MA-LTC Eligibility Requirements MA-LTC eligibility requirements for the BI waiver are: Be under age 65. Be certified disabled by SSA or SMRT. Meet all MA eligibility requirements. Require an institutional level of care as determined by a long-term care consultation (LTCC) completed within the past 60 calendar days which indicates that services are anticipated to begin within the next 30 days. Have a home equity of $543,000 or less (unless exempt). Name DHS as a preferred remainder beneficiary on certain annuities. Not be subject to a transfer penalty. Introduction to LTCFs and Waivers 12 Rev.12/10/13 Health Care Training

12 DD CRITERIA What is the DD Waiver? The purpose of the Developmental Disability program, administered by the DHS Disability Services Division, is funding home and communitybased services for children and adults with developmental disabilities or related conditions. People requesting the DD waiver require an ICF/DD or nursing facility level of care. Covered Services Examples of covered services include: Basic MA covered services. DD covered services including but not limited to: o o o o o o Day training and habilitation services. Supported living services. Respite care. Home maker services. Case management. Assistive technology. Transitional services. MA-LTC Eligibility Requirements MA-LTC eligibility requirements for the DD waiver are: Determined to have a developmental disability or related condition by a case manager. Meet all MA eligibility requirements. Require an institutional level of care as determined through a full team DD screening. Have a home equity of $543,000 or less (unless exempt). Name DHS as a preferred remainder beneficiary on certain annuities. Not be subject to a transfer penalty. Introduction to LTCFs and Waivers 13 Rev.1/13/13 Health Care Training

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14 LTCF AND WAIVER PROGRAMS ELIGIBILITY CRITERIA SUMMARY Additional Care Need For Case Management Provided By Level of Care Needed Screening Community Alternative Care (CAC) Person who is chronically ill or medically fragile County Social Services County Public Health Department Community Alternatives for Disabled Individuals (CADI) Person with a disability County Social Services County Public Health Department Managed Care Plans Hospital Institutional / SNF LTCC approving need for CAC waiver required (DHS- 5181) LTCC approving need for CADI waiver required (DHS-5181) Developmental Disability (DD) Person with a developmental disability or a related condition County Social Services Elderly Waiver (EW) Person age 65 or over County Social Services County Public Health Department Tribal agencies Managed Care Plans ICF/DD or SNF Institutional / SNF Full Team DD Screening approving need for DD waiver required (DHS- 5181) LTCC approving need for EW required (DHS- 5181) Long Term Care Facility (LTCF) Person requires placement in skilled nursing facility Managed Care Plans Institutional PAS required, unless exempt (DHS-1503) Brain Injury (BI) Person with an acquired, traumatic or degenerative brain injury County Social Services County Public Health Department Managed Care Plans Institutional Neurobehavior al hospital LTCC approving need for BI waiver required (DHS- 5181) Introduction to LTCFs and Waivers 14 Rev. 03/22/13 - Health Care Training

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16 MA-LTC BASICS COURSE OBJECTIVES MA-LTC Forms Identify forms used to request MA-LTC. Explain what happens to eligibility for MA-LTC until the appropriate request form is received. Processing MA-LTC Requests Determine if an interview is needed. Identify ways clients may authorize a person to represent them. Level of Care Requirement Identify the purpose of the LTC screening. List people who are a part of the LTCC team. Identify when an LTC screening is required for MA-LTC. Identify the form used to determine if an LTC screening has been completed for a person requesting MA-LTC through a waiver program. Explain communication best practices established to facilitate communication between you and the waiver case manager. Locate information on the Lead Agency Case Manager/Worker Communication form (DHS-5181) needed to determine eligibility for MA-LTC. Refer clients to your county LTCC team as needed. Explain the difference between an LTC screening for a waiver program and one for an LTCF admission. Identify the form used to verify that the preadmission screening (PAS) has occurred for a person residing in an LTCF. Locate information on the Physician Certification form (DHS-1503) needed to determine eligibility for MA-LTC. Complete an LTC/County Communication Form (DHS-3050). Training Caseload Use the Long-Term Care and Waiver Case Checklist (DHS-5590) to help you process MA-LTC eligibility. Complete Steps 1 and 2 of the MA-LTC Processing Steps on five MA- LTC cases. MA-LTC Basics 1 Rev. 03/27/13 - Health Care Training

17 MA-LTC BASICS COURSE OBJECTIVES General Requirements Determine the basis of eligibility for a person requesting MA-LTC. Identify basic MA eligibility criteria as they apply to MA-LTC. Community Spouse Define the terms community spouse and long-term care (LTC) spouse. Determine whether an MA-LTC client s spouse qualifies as a community spouse. Identify the MA-LTC policies impacted if a client s spouse qualifies as a community spouse. Household Size Determine the household size for a person requesting MA-LTC. Asset Requirements Identify when assets are verified and reviewed. Explain asset deeming rules for clients requesting MA-LTC. Recall the asset limits for clients requesting MA-LTC. Determine when someone is exempt from asset limits for MA-LTC. Determine if an MA Lien Worksheet (DHS-3203) must be completed and sent to the DHS Special Recovery Unit. Determine when to exclude the homestead. Third Party Liability Determine when a parental fee is required. Explain Medicare coverage as it pertains to people requesting MA-LTC. Home Equity Limit Explain when the Home Equity Limit requirement is applied. Identify when acceptable verification has been provided in order to apply the Home Equity Limit. Define the term agricultural homestead. Explain notice requirements as they apply to the Home Equity Limit. Apply the Home Equity Limit. MA-LTC Basics 2 Rev. 03/27/13 - Health Care Training

18 MA-LTC PROCESSING STEPS Follow the steps provided when a request for MA-LTC is received. 1. Determine if the following MA-LTC request forms (or ApplyMN online application) are complete, or if additional information is needed: DHS-3531, MHCP Application for Payment of Long-Term Care and Waiver services. DHS-3543, Request for MA Payment of Long-Term Care Services for an MA enrollee or along with the HCAPP or CAF for an applicant. 2. Review the request form. Request required verifications. Encourage an applicant to complete an interview and schedule upon request. Determine the begin date for MA-LTC clients in an LTCF or the anticipated begin date for waiver clients. 3. Determine if MA eligibility requirements are met as applied to MA-LTC. Basis of Eligibility. SSN. Citizenship and Identity. Immigration Status. Minnesota Residence. Living Arrangement. Asset Eligibility, including Asset Assessment as appropriate. Third Party Liability. Make appropriate referrals. 4. Determine if additional MA-LTC eligibility requirements have been met. Age Requirements, as appropriate. Institutional Level of Care Required. Home Equity Limit. Annuity Requirements. Transfer Evaluation. MA-LTC Basics 3 Rev. 03/27/13 Health Care Training

19 MA-LTC PROCESSING STEPS 5. Calculate Income. Determine the appropriate income calculation to use. Determine when to begin using the appropriate income calculation. 6. Determine the spenddown or waiver obligation. 7. Approve or deny eligibility in MAXIS. 8. Update MMIS. 9. Enter case notes. MA-LTC Basics 4 Rev. 03/27/13 Health Care Training

20 FORMS USED TO REQUEST MA-LTC Form Name Form Number Notes Minnesota Health Care Programs Application for Payment of Long-Term Care Services DHS Minnesota Health Care Programs - Request for Payment of Long-Term Care Services 3543 Minnesota Health Care Programs Application (HCAPP)- Obsolete 1/1/ Combined Application Form (CAF)- Health Care request removed 1/1/14. DHS- DHS- DHS MNsure Application for Health Coverage and Help Paying Costs with Supplement Online- MNsure website 6696 and or the DHS- DHS- 6696A MA-LTC Basics 5 Rev.1/6/14 Health Care Training

21 FORMS USED TO REQUEST MA-LTC Applicants may apply using ApplyMN, Minnesota s online application, with a request for waiver services (questions under the Program Details section of the application) or through the LTCF-specific application path, Payment of services in a Long-Term Care Facility. ApplyMN substitutes for the MN HC Programs Application for LTC Service ( DHS-3531). MA-LTC Basics 6 Rev.1/6/14 Health Care Training

22 NAME THAT FORM! Circle the MA-LTC request form that is appropriate for each of the scenarios below. 1. Randolph is an MA enrollee who enters a long-term care facility (LTCF). a. DHS-3531, MHCP Application for Payment of Long-Term Care Services. b. DHS-3543, MHCP Request for Payment of Long-Term Care Services. c. No form is needed. 2. Julia is a current MA enrollee. MA-LTC was closed two months ago when she was discharged from an LTCF. Julia is now requesting home and community-based services through the Elderly Waiver. a. DHS-3531, MHCP Application for Payment of Long-Term Care Services. b. DHS-3543, MHCP Request for Payment of LTC Services. c. No form is needed. 3. Rhonda moved into an LTCF yesterday. She was receiving home and community-based services through the Elderly Waiver prior to her admission. a. DHS-3531, MHCP Application for Payment of Long-Term Care Services. b. DHS-3543, MHCP Request for Payment of LTC Services. c. No form is needed. 4. Sweeny contacts the county to apply for MA and MA payment of LTC services because he is requesting services through the Elderly Waiver. a. DHS-3531, MHCP Application for Payment of Long-Term Care Services. b. DHS-3543, MHCP Request for Payment of LTC Services. c. No form is needed. MA-LTC Basics 6 Rev. 03/27/13 Health Care Training

23 DETERMINING THE BEGIN DATE OF MA-LTC Factors Use the following factors to determine the begin date for MA-LTC: Date the request for MA-LTC is received at the county. Date of admission for clients residing in an LTCF, or if in a hospital, the date skilled nursing facility services began. Date the case manager anticipates services will begin based on the LTCC for clients requesting services through one of the home and community-based waiver programs. Begin Date Rules Follow these rules based on living arrangement when determining the begin date for MA-LTC for the following clients: Residents of an LTCF. The begin date for a person residing in an LTCF is the date on which all of the following is true: The client resided in the LTCF or began receiving skilled nursing facility services in a hospital. The client requested coverage for that month. The client meets all eligibility requirements for MA-LTC. People requesting services through a home and community-based waiver program. The begin date for a person requesting services through one of the home and community-based waiver programs is the date on which all of the following is true: The case manager anticipates services will begin based on a LTCC. The client requested coverage for that month. The client meets all eligibility requirements for MA-LTC. MA-LTC Basics 7 Rev. 03/27/13 Health Care Training

24 PROCESSING MA-LTC REQUESTS REVIEW Read each scenario and answer the questions. Scenario 1 Kara, who is not an MA enrollee, is requesting MA-LTC on December 12 and is requesting three months of retroactive coverage. She was admitted permanently to an LTCF on October 3. Her newly designated authorized representative, her daughter, is helping her to apply and is requesting a meeting with Kara s worker. No prior AREP designation is on file. 1. Who must sign the request form? 2. Do you have to meet with the authorized representative? 3. What is the begin date for MA-LTC? Scenario 2 Jacob, an MA enrollee for the past two years, is requesting MA-LTC on December 12. He was admitted to the LTCF on August What do you need to do if you are waiting for the DHS-3543 to be submitted? 5. How do you verify Jacob requires an institutional level of care? 6. What is the begin date for MA-LTC? Scenario 3 Mandy is requesting MA-LTC through the Elderly Waiver on December 12. She is requesting one month of retroactive coverage. Her LTCC took place on December 2, anticipating services to begin on this same date. 7. How do you verify Mandy requires an institutional level of care? 8. What is the begin date for MA-LTC? Scenario 4 Joey is ineligible for MA when his parents income is deemed. Eligibility is being determined using the TEFRA option. 9. Who is required to sign the request form? 10. What is the begin date for MA-LTC? MA-LTC Basics 8 Rev. 03/27/13 - Health Care Training

25 DHS-5181 PROCEDURES The Lead Agency Case Manager/Worker Communication Form (DHS- 5181) was developed to help with communication between the waiver case manager and the financial worker. The form is required in the situations recorded below. Waiver Case Manager The case manager is required to immediately send the DHS-5181 in the following situations: Situation Send Form Comments LTCC and full team DD screening indicates waiver services are needed. Immediately. The LTCC date or the anticipated begin date of services if different than the A change occurs such as a change in waiver program, living arrangement, address, managed care plan, or other type of change. Client death. Immediately. Immediately. LTCC date. Note the change. Worker You are required to send the form to the waiver case manager within certain timeframes based on specific situations. Send the form: Situation Send Form Comments A change occurs such as death, Immediately. Note the change. living arrangement, address change, LTC spenddown or waiver obligation changes, or other types of changes. MA is approved, denied or closed. Immediately. MA-LTC is approved, denied or Immediately. ending. Case manager sends DHS-5181 initially and MA-LTC is pending. Eligibility continues to pend and the processing period is ending. Within 10 working days of receipt of DHS days from the receipt of the DHS Indicate if additional information is needed for processing. Indicate why eligibility is pending. MA-LTC Basics 9 Rev. 03/27/13 Health Care Training

26 DHS-5181 ACTIVITY Circle both the person responsible to send a DHS-5181 and when the form must be sent in each of the following situations. 1. Louisa, an MA enrollee, contacts Anoka County Social Services to request services that will enable her to continue to live in her home. An LTCC is completed on April 1. Who When a. Case Manager a. Immediately b. Worker b. Within 10 days c. Neither c. On the 45 th day d. Not Required 2. Rhonda is an MA-LTC enrollee receiving services through the EW. Her daughter calls Rhonda s worker to report Rhonda s death. Who When a. Case Manager a. Immediately b. Worker b. Within 10 days c. Neither c. On the 45 th day d. Not Required 3. Jake resides in an LTCF. His LTC spenddown amount is changing. Who When a. Case Manager a. Immediately b. Worker b. Within 10 days c. Neither c. On the 45 th day d. Not Required 4. Frank, an MA enrollee, was given a DHS-3543 to complete at the time of his LTCC on January 7. The waiver case manager sent a DHS-5181 to the worker on the day of the LTCC indicating the application form was provided. Frank returned the DHS-3543 on January 10. Frank s eligibility is pending for income verification. Who When a. Case Manager a. Immediately b. Worker b. Within 10 days c. Neither c. On the 45 th day d. Not Required MA-LTC Basics 10 Rev. 03/27/13 Health Care Training

27 LTC SCREENING ACTIVITY Determine if the statement for each of the following scenarios is true or false. 1. A PAS is used to document an institutional level of care for a person who is requesting MA-LTC services for Elderly Waiver. True False 2. The purpose of the PAS is to prevent inappropriate LTCF placement. True False 3. The LTCC team will make the final decision for a client as to when she can be placed in an LTCF or if she is able to remain in her home with support services. True False 4. A PAS is not required for a person transferring from one Minnesota LTCF to another Minnesota LTCF. True False 5. A PAS is required for a person, who previously lived in the community, and was admitted to an LTCF on an emergency basis. True False 6. If a current MA enrollee refused the LTC screening, his current eligibility for basic MA would be terminated. True False MA-LTC Basics 11 Rev. 03/27/13 - Health Care Training

28 GENERAL MA REQUIREMENTS REVIEW Bases of Eligibility 1. List the bases of eligibility available for people residing in an LTCF or requesting services through a waiver program. LTCF* Bases of Eligibility Available for Use EW CAC* CADI* DD* BI* *Children receiving adoption assistance must use the appropriate adoption assistance basis of eligibility. Basic MA Eligibility Criteria 2. Which three eligibility criteria follow basic MA rules when processing MA-LTC? Residency/Living Arrangement 3. Why is it important to determine how a person was placed in a facility? 4. Why is it important to know whether an LTCF is considered a Medicaid facility when a person is requesting MA-LTC? MA-LTC Basics 12 Rev. 03/27/13 - Health Care Training

29 SPOUSE ACTIVITY A spouse is a person who is legally married to another person; a husband or a wife. The legal marriage must be a union legally recognized in Minnesota. A legal separation does not dissolve the union for MA-LTC purposes. Activity Directions Read each scenario and determine whether or not the person requesting MA-LTC has a spouse. 1. Bernice and Ron live together with their 15-year-old son. They were never legally married. Bernice is requesting MA-LTC through the EW. Spouse No Spouse 2. Christy and Justin were married two years ago by a Minneapolis judge. Justin enters an LTCF and is requesting MA-LTC. Spouse No Spouse 3. Sistine has been married to Sylvester for 25 years. They have been separated for 15 of those 25 years. Sistine is requesting MA-LTC through the EW. Spouse No Spouse 4. Mark is a single father living with his 17-year-old daughter. He is requesting MA-LTC due to placement in an LTCF. Spouse No Spouse MA-LTC Basics 13 Rev. 03/27/13 - Health Care Training

30 LTC AND COMMUNITY SPOUSE ACTIVITY LTC Spouse: A person is an LTC spouse if he/she is married to a community spouse and: Resides in a long-term care facility (LTCF) and has resided, or is anticipated to reside, in an LTCF for at least 30 consecutive days, or Requests services through the Elderly Waiver (EW) or Alternative Care (AC) programs and has received, or is anticipated to receive, EW or AC services for at least 30 consecutive days. Community Spouse: A person who does not reside in a long-term care facility (LTCF) or receive services through a waiver program (EW, CAC, CADI, DD or BI) who is married to a long-term care (LTC) spouse. A community spouse may receive basic MA or services through the AC program. Activity Directions Identify the LTC spouse and community spouse in each of the following scenarios. 1. Christy and Justin were married two years ago by a Minneapolis judge. Justin enters an LTCF on October 1 and requests MA-LTC services on October 15. He is not expected to be discharged from the facility. Christy is an MA enrollee. LTC Spouse: Community Spouse: 2. Sistine has been married to Sylvester for 25 years. They have been separated for 15 of those 25 years. An LTCC completed on April 15 approves Sistine for the CADI waiver. Sistine applies for MA-LTC on April 16 is found eligible. Sylvester lives in his own home and continues to receive services through the EW for the past year. LTC Spouse: Community Spouse: 3. Mark and Amy are married. Mark s 17-year-old daughter lives with the couple. He applies for MA-LTC the day after his LTCC indicates he is approved for EW services indefinitely. Amy is not requesting MA or MA- LTC. LTC Spouse: Community Spouse: MA-LTC Basics 14 Rev. 03/27/13 Health Care Training

31 HOUSEHOLD SIZE REVIEW 1. Indicate the household size to use for the resident of the LTCF in each of the situations listed. Community Spouse MA-LTC MSP Month of Admission to LTCF Month after Admission to LTCF No Community Spouse MA-LTC MSP 2. Indicate the household size for the EW client and for other household members during the month waiver services are anticipated to be received. Month of EW Services Anticipated to Begin Month after EW Services Anticipated to Begin Client Other HH Members Client Other HH Members Community Spouse MA- LTC MSP No Community Spouse MA- LTC MSP MA-LTC Basics 15 Rev. 03/27/13 Health Care Training

32 HOUSEHOLD SIZE REVIEW 3. Indicate the household size for the disability waiver client and for other household members during months waiver services are anticipated to be received. Client Other Household Member MA-LTC MSP MA MSP CAC CADI DD BI MA-LTC Basics 16 Rev. 03/27/13 Health Care Training

33 MA-LTC ASSET DEEMING LTCF Community Spouse No Community Spouse MA-LTC QMB SLMB EW Community Spouse No Community Spouse CAC CADI DD BI MA-LTC Basics 17 Rev. 03/27/13 Health Care Training

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35 ASSET LIMITS FOR MA-LTC LTCF EW Community Spouse No Community Spouse Community Spouse No Community Spouse MA-LTC QMB SLMB $3,000 (Method B) or $10,000 $10,000 $10,000 (Method A) for months of LTCF residence. $3,000/$6,000 /+$200 $10,000/$18,000 (Method B) or for month of $10,000/ entry. $20,000 (Method A) for $10,000 for entry month. months following $3,000 month of entry. (Method B) or $10,000 (Method A) for months following entry month. $3,000 for months services anticipated to be received. $3,000/$6,000 /+$200 (Method B) for month services are anticipated to be received. $3,000 for months following the month services anticipated to be received. $10,000/$18,000 for month of entry. $10,000 for months following month of entry. $10,000 $10,000 $10,000 $10,000 MA-LTC Basics 18 Rev. 03/27/13 Health Care Training

36 ASSET LIMITS FOR MA-LTC MA-LTC QMB SLMB CAC CADI DD BI $3,000 for months services received. $3,000 for months services received. $3,000 for months services received. $3,000 for months services received. $10,000/$18,000 based on household size. $10,000/$18,000 based on household size. $10,000/$18,000 based on household size. $10,000/$18,000 based on household size. $10,000/ $18,000 based on household size. $10,000/ $18,000 based on household size. $10,000/ $18,000 based on household size. $10,000/ $18,000 based on household size. Note: Children under age 21, pregnant women, people receiving automatic MA, MA for adults without children enrollees, and others, are exempt from the asset limits listed. See the HCPM for more information about other people exempt from the asset limit. MA-LTC Basics 19 Rev. 03/27/13 Health Care Training

37 MA-LTC CLIENTS EXEMPT FROM ASSET LIMITS This handout contains asset information for MA-LTC applicants and enrollees who are exempt from an asset limit including AX adults without children who are not eligible for MA-LTC under another MA basis of eligibility. MA-LTC applicants/enrollees who are exempt from an asset limit, including children under 21, pregnant women, and AX adults without children, must meet the following MA-LTC requirements: Meet all basic MA eligibility requirements. Require an institutional level of care. Have home equity of $543,000 or less. Name DHS as a preferred remainder beneficiary of certain annuities owned by the person or the person s spouse. Comply with LTC insurance (LTCP) requirements, if applicable. MA-LTC clients who are exempt from asset limits are exempt from the following asset-related MA-LTC requirements: If a community spouse exists, they are not required to complete an asset assessment because there is no asset limit. However, a requested asset assessment must be determined if requested by the household when an initial 30-day period of institutionalization occurs. The receipt of LTC services establishes an effective date for an asset assessment. The asset assessment may become required if the enrollee becomes eligible for MA under a basis that has an asset limit. Note: Most AX LTC enrollees will have short-term eligibility under this basis. If an AX enrollee remains in a facility, they must cooperate with a disability determination through SSA and/or SMRT. Asset transfers are not evaluated, and penalties not set, if a client qualifies for MA-LTC under these bases of eligibility because there is no asset limit. Continue to follow income transfers policy in regards to MA-LTC eligibility. MA-LTC Basics 20 Rev.1/13/13 Health Care Training

38 PRE-DEATH LIENS Follow the steps provided below to determine if a pre-death lien must be filed on real property owned by an MA-LTC client. 1. Determine if the MA-LTC client resides in an LTCF, ICF/DD or an inpatient hospital. If the client: Does reside in one of the facilities, continue to Step 2. Does not reside in one of the facilities, a pre-death lien is not required. 2. Determine if the MA-LTC client is expected to remain permanently in the facility. If the client: Is expected to permanently remain in the facility, continue to Step 3. Is not expected to permanently remain in the facility, a pre-death lien is not required. 3. Complete and send the MA Lien Worksheet (DHS-3203) to DHS Special Recovery Unit (SRU). SRU will determine whether or not a lien should be filed. Pre-Death Lien Exemptions If real property meets any of the following situations, a pre-death lien exemption is met. It is the homestead of the person s spouse. It was the client s homestead at the time the client entered the facility and any of the following people now live in the property: o The client s child who is under 21. o The client s child, of any age, who meet all of the following conditions: Lived in the home for at least two years before the client began receiving institutional care. Provided care that allowed the client to remain in the community. Has lived in the home continuously since the client entered the institution. The client s sibling who meets all of the following conditions: o Has an equity interest in the homestead. o Resided in the home for at least one year before the person entered the institution. The income, resources and/or property meet an exemption for American Indians. Exemptions do not preclude the need to file a DHS-3203 with the SRU. MA-LTC Basics 21 Rev. 03/28/13 - Health Care Training

39 ASSET REVIEW Complete the chart for each of the following scenarios. 1. Emilio (age 57) is requesting MA-LTC due to residence in an LTCF. He receives RSDI disability payments. He lived with his sister prior to his admission on January 19. Household Size Deeming Asset Limit January February January February January February MA-LTC MSPs 2. Carla (age 75) lives with her husband, Ellis, in their home. Carla had an LTCC and requested MA-LTC on January 15 through the EW. Ellis is not requesting coverage and does not receive any LTC services. Household Size Deeming Asset Limit January February January February January February MA-LTC MSPs 3. Jim (age 54) lives with his wife, Peg. Jim had an LTCC and requested MA-LTC on January 17 through a disability waiver (CAC, CADI, DD or BI). Peg is not requesting coverage and does not receive LTC services. Household Size Deeming Asset Limit January February January February January February MA-LTC MSPs MA-LTC Basics 22 Rev. 03/28/13 Health Care Training

40 HOMESTEAD EXCLUSION FOR LTCF RESIDENTS Use the exclusion reason below that allows for the longest exclusion period. First Six Calendar Months Exclude for the first six months of placement. To determine the six calendar months of exclusion start with the first full calendar month in which the client resides in the LTCF. Intent to Return Home Exclude for as long as the client intends to and reasonably expects to return home. Residence of Spouse, Child under 21 or Disabled Child Exclude for as long as it is the residence of the LTCF resident s spouse, child under 21 or disabled child of any age. Residence of Sibling Exclude for as long as it is the residence of the LTCF resident s sibling when both of the following conditions are met: Residence of Non-Disabled Adult Child or Grandchild Exclude for as long as it is the residence of the LTCF resident s adult child or grandchild when both of the following conditions are met: MA-LTC Basics 23 Rev. 03/28/13 - Health Care Training

41 MA-LTC AND PARENTAL FEES Parents may be liable for a fee to reimburse part of their children's costs in any of the following situations: The custodial parents do not live with their minor children. The parents income is not considered in determining MA eligibility. This is the case when a child receives services through a waiver program or MA through the TEFRA Option. A child resides in an LTCF. Referral Process Follow the steps below to refer cases to DHS for collection of parental fees: 1. Give a copy of the Important Notice and Parental Fee Worksheet (DHS- 2977) to all parents of children for whom DHS will collect fees. Explain to parents that their liability for parental fees begins with the first month in which MA is effective or waiver services are received and that they may be liable for a fee through the month of the child's 18th birthday. Parents can estimate the amount of the fee using the Parental Fee Estimator located on the DHS website at: 2. Enter the proper eligibility type (DX or BX) on MMIS to enable DHS to bill and collect a parental fee. Notify DHS any time an eligibility change is made. See the MMIS User Manual for coding information. 3. Within ten days of approving MA, send a completed County Parental Fee Referral to DHS (DHS-2982) to the address noted on the form. Refer to the Health Care Programs Manual (HCPM) for more information on Parental Fees. MA-LTC Basics 24 Rev. 03/28/13 Health Care Training

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43 MEDICARE Alternative Name Covered Services Potential Coverage Service Delivery Part A Part B Part C Part D Medigap Policy Original Medicare Original Medicare Advantage Prescription Drug Medicare Medicare Coverage Supplement Hospitalization, SNF Care, Hospice, Home Health Services Medically- Necessary and Preventative Services Part A and Part B Covered Services N/A N/A Portion of Part B Premium Part D Covered Services Other Services (vary by plan) Medicare Fee-For-Service Medicare Fee-For-Service Private Health Plan Network Plan Fee-For- Service Prescription drug coverage (varies by plan see plan formulary for specific coverage) N/A Private Health Plan Network Insurance Part A and Part B Cost-Sharing Amounts (vary by plan) Other services vary by plan Prescription Drug Coverage (limited) Medicare Fee- For-Service MA-LTC Basics 25 Rev. 03/28/13 Health Care Training

44 MEDICARE Costs Medical ID Card Used Review MSP Eligibility Part A Part B Part C Part D Medigap Policy Premium, if Premium* Part A and B Premium Premium based applicable* (varies) premiums (plan varies by plan on chosen plan Cost-sharing Cost-sharing may pay for a Cost-sharing amounts amounts portion see amounts (vary HCPM ) by plan) Cost-sharing amounts (vary by plan) Premium and costsharing amounts for extra coverage (vary by plan) Medicare Medicare Health Plan Health Plan Medicare and Health Plan Yes Yes Yes Note: MSP covers the portion of the Part A/B premiums and/or Part B cost-sharing amounts for which the client is responsible. See HCPM No Note: MA-eligible clients have Part D premium up to the benchmark covered by Extra Help. Check HCPM Benchmark document. No MA-LTC Basics 26 Rev. 03/28/13 Health Care Training

45 MEDICARE STAT/BILS *Amounts available in SVES response panel - Beneficiary Data Response (BDXM). STAT/MEDI STAT/INSA MMIS TPL Part A Part B Part C Part D Medigap Policy Enter each for Enter each for Enter each for which Enter each for Enter each for which the client is which the client the client is which the client is which the client is responsible: is responsible: responsible: responsible: responsible: Premium Premium Premium amount Premium Premium amount if using amount if Cost-sharing amount amount to meet using to meet amounts, such as Co-payments Cost-sharing spenddown* spenddown* copayments, amounts, such Deductibles Deductibles deductibles, etc. as Coinsurance Coinsurance copayments, deductibles, etc. Update: Begin and end dates Premium amount paid by client, if any* Update: Begin and end dates Premium amount paid by client* Indicator to apply to spenddown No Note: Enter Part A and Part B information, including premium amounts not covered by the Part C plan No No Update No Update No No Update Exception: MSHO or SNBC clients. No No No Update MA-LTC Basics 27 Rev. 03/28/13 Health Care Training

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47 MEDICARE PART A Medicare is a federal health insurance program for people age 65 or older, disabled and under age 65, or any age with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant). Part A: Hospitalization Insurance Coverage Hospitalization Skilled Nursing Facility Care Costs Clients are responsible for: A deductible of $1,163 (2014) for hospital stays that are days or less. Coinsurance of $304 (2014) per day for days -. Coinsurance of $608 (2014) per day for days -. All costs after day. Coverage begins only if there is a qualifying stay of at least 3 consecutive days of hospitalization and the person enters a Medicare certified skilled nursing facility within 30 days of discharge from the hospital. This coverage is limited to days in one benefit period beginning the day of entry into the facility. Limited hospice care Limited home health care The first days are paid in full by Medicare. The remaining days require a co-payment of $ (2014) per day. Hospice is a special way of caring for people, and their family, who are certified terminally ill and expected to live 6 months or less. Hospice care may be provided in the home, or a facility such as a nursing home. Medicare covers the cost of the first home health visits following a hospital stay. MA-LTC Basics 28 Rev.12/11/13 Health Care Training

48 HOME EQUITY LIMIT A person requesting or receiving MA-LTC, who has an ownership interest in their home, must have an equity value at or below $543,000 to be eligible. Exceptions Verification Verify EMV or FMV at application, at and when a home equity exception ends. Use the county assessor s website to verify the EMV of the home. Request proof from the client if the information is not available. Verify client encumbrances on the property when the EMV or FMV exceeds $ Equity Exceeds Limit Update MMIS/RLVA to inhibit payment of LTC services. Send 10-day notice to enrollee to close payment of LTC services. Send a Notice of Action for Payment of LTC of Services (DHS-4915) to notify the client of the denial when a MAXIS notice is not created. Provide appropriate notice text and case note the action taken. Worker Comment Text Applicant Denial: "Medical Assistance (MA) will not pay for your long-term care services because your home has an equity value of more than $543,000. (Minnesota Statutes, Section 256B.056, subd. 2) Call your county worker right away if you feel your life will be in danger as a result of losing MA payment for your long-term care services." Enrollee Closure: "Starting (add date) Medical Assistance (MA) will no longer pay for your long-term care services because your home has an equity value of more than $543,000. (Minnesota Statutes, Section 256B.056, subd. 2) Call your county worker right away if you feel your life will be in danger as a result of losing MA payment for your long-term care services." MA-LTC Basics 29 Rev.1/13/13 Health Care Training

49 ASSET ASSESSMENT COURSE OBJECTIVES The Basics Explain the purpose of the asset assessment. Define the following terms: o LTC Spouse. o Community Spouse. o Continuous Period of Institutionalization. o Community Spouse Asset Allowance. o Asset Assessment Effective Date. Identify forms used in the asset assessment process. Policy 101 Identify when an asset assessment is required. Determine the asset assessment effective date. Explain when an asset assessment may be requested or required. Explain asset assessment verification requirements. Asset Evaluation Evaluate verified assets based on asset assessment rules to determine if those assets are counted (non-excluded) or excluded. Determine the couple s total countable assets. Community Spouse Asset Allocation Determination Determine the appropriate minimum and maximum asset allowance figures to use at the time of a requested asset assessment or at the time of a required asset assessment when MA-LTC services are requested. Calculate the estimated and actual community spouse asset allowance. Request for MA-LTC Explain how the community spouse asset allowance is used to determine whether the client is asset-eligible for the request for MA- LTC. Explore when a reduction of excess assets must occur. Determine when assets must be transferred prior to approval of MA- LTC. Process the first annual renewal. MA-LTC Training Case Process a requested asset assessment. Use an asset assessment to determine asset eligibility at the time of a request for MA-LTC. Asset Assessment 1 Rev. 03/06/13 Health Care Training