ATTACHMENT #2 DHS INSTRUCTIONS FOR DETERMINING A MEMBER'S INCOME AVAILABLE TO PAY FOR ROOM AND BOARD IN SUBSTITUTE CARE

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1 ATTACHMENT #2 DHS INSTRUCTIONS FOR DETERMINING A MEMBER'S INCOME AVAILABLE TO PAY FOR ROOM AND BOARD IN SUBSTITUTE CARE Instructions: The instructions are for the purposes of determining a member s contribution to room and board in community substitute care settings (CBRF, AFH, RCAC) with the online automated version available through Program Participation System (PPS). Completed data will be uploaded into the DHS database and there is not need for the MCO to keep a copy unless the MCO would like to keep a copy in the member s case file The person completing the form must use the line-by-line instructions on the following pages. They identify where the information to be entered can be obtained. The underlying requirements for what information is to be used as income and what may be excluded from income available to pay room and board are also cited as hyperlinks. Line-by-Line Instructions for Determining Income Available to Pay for Room and Board in Substitute Care in PPS (online automated version) Room & Board Information 1. Select Responsible Agency 2. Select County 3. Select Facility Type 4. Status no entry needed 5. Last Updated Date no entry needed 6. CARES Lookup Date no entry needed 7. Current MA Eligibility no entry needed verify that it is Family Care, Partnership or PACE 8. Estimated MA End Date no entry needed verify that the member is currently MA eligible 9. Waiver Group no entry needed Income Information 10. Enter Net Monthly Earned Income. Net Monthly Earned Income is all income from employment after deducting state income taxes and federal income taxes (including Social Security, FICA and Medicare taxes) that have been withheld. [DHS 1.03 (3)] Obtain the earned income amount from the individual s pay stubs or most recent income tax forms. Use this information to calculate average monthly net income. Net income is income after deductions noted above. The CARES system records the individual s Gross monthly earned income. Net monthly earned income is required for determining income available to pay for room and board in substitute care. Income should be verified annually, generally at the time of review. However enrollees should be reminded to report any changes that occur throughout the year. Changes should be reported to both the Income Maintenance Worker and the Managed Care Organization. For more information on the requirement to report changes see the Medicaid Eligibility Handbook Section The IM worker s name will appear on any notices of decision related to reported changes. 11. Verify/Enter Total Monthly Unearned Income is Income from pensions, annuities, interest, etc. Unearned Income information can be found on the Unearned Income pages or the Unearned Income Summary page in CARES Worker Web. (See CARES Worker Web Access Information on page 5.) [DHS 1.03(2)] 12. Total Calculated field no entry needed PPS will add the Net Monthly Earned Income + Total Monthly Unearned Income Allowance & Deduction Information 13. Earned Income Disregard no entry needed the first $65 plus ½ of remaining earned income. (If the member s total earned income is less than $65, the entire amount of Earned Income is entered here.) The Earned Income Disregard is income retained by the member for personal use: the higher the earned income, the more the member retains. The member or his representative must ensure that accumulated income does not result in excess assets, or s/he may risk ineligibility. Note that MAPP (Medicaid Purchase Plan) has a higher asset limit and that BadgerCare Plus has no asset limit. [DHS 1.03 (3)] 14. Unearned Income Disregard $20 no entry needed. 1

2 15. Discretionary Income Allowance no entry needed. The discretionary income allowance is approved by DHS for each service area at either $80 or $100. It assures that members have that minimum amount reserved for personal use. The amount on this line supplements the disregarded income on lines 13 and 14 to assure that the member has a minimum of either $80 or $100 reserved. If the disregarded income on lines 13 and 14 exceeds the $80 or $100 minimum, there is no additional discretionary income allowance and the amount on this line will be $0. [DHS 1.03(4)] 16. Verify/Enter Health Insurance Premiums. Health Insurance Premiums must be paid out-of-pocket from this member s income (i.e., if spouse is paying the premium, do not use this deduction). For a full a definition of Health Insurance see the Medicaid Eligibility Handbook Section Health Insurance. Include all health and dental insurance premiums covering the member and for which s/he is responsible and pays a premium. This includes any Medicare Premium obligation including Medicare Part D, MAPP or BadgerCare Plus premiums. Insurance types for which premium deductions are not allowed can be found in the Medicaid Eligibility Handbook Section Policies Not to Report. If the member is part of a covered group, but not responsible for the premium, find his/her proportionate share by dividing the premium by the number of people covered. If both members of a couple apply, but only one pays the premium, divide the premium equally. Convert any payment for which the member is responsible to a monthly premium. For example, if the member pays a $600 premium quarterly for a Medicare supplement policy, divide $600 by three months to convert to a $200 monthly premium amount. Health Insurance Premium information can be found on the Medical Coverage Page in CARES Worker Web. 17. Verify/Enter Medical/remedial expenses must be paid out-of-pocket by the person. The definition of medical/remedial expenses can be found in the Medicaid Handbook Section Medical/Remedial Expenses (MRE). See also Appendix E: Medical Remedial Expenses Frequently Asked Questions, Worksheet and the medical/remedial expenses checklist. Medical expenses are anticipated incurred expenses for services or goods that have been prescribed or provided by a professional medical practitioner (licensed in Wisconsin or another state) for diagnosis, cure, treatment, or prevention of disease or for treatment affecting any part of the body. These are expenses that are the responsibility of the member, and cannot be reimbursable by any other source, such as Medicaid, private insurance, or employer. The following are examples (not an all-inclusive) of medical expenses: Deductibles and co-payments for Medicaid, Medicare, and private health insurances Bills for medical services which are not covered by the Wisconsin Medicaid program For purposes of meeting a Medicaid deductible, medical services received before the person became eligible for Medicaid Remedial expenses are costs incurred for services or goods that are provided for the purpose of relieving, remedying, or reducing a medical or health condition. If an item can be covered in the Family Care, or Partnership benefit package it is not a remedial expense. Certain medical/remedial expenses cannot be counted. See operations memos: Medical/Remedial Expenses Used for LTC Medicaid Eligibility and Cost Sharing IM operations Memo: and DLTC memo: Medical/remedial expense information can be obtained: For Group A individuals from the applicant/member. For Group B individuals from the Community Waivers Budget Screen in CARES Worker Web. For Group C married individuals from the Spousal Income Allocation Worksheet, Section C, Line 10. (See the definition of single below.) For Group C single individuals enter zero. The person should not have out-of-pocket medical/remedial expenses that are not already used to offset Group C spenddown liability. If the person does have MRE costs in excess of those counted to offset spenddown liability, refer this situation to the MCO fiscal office to correct the monthly spenddown liability collected. (Note: The definition of single includes the following: an unmarried individual, or an individual whose spouse resides in an institution, or an individual whose spouse has been enrolled in an MCO or in a COP W program for one year or longer.) 2

3 18. Enter Special Exempt Income. Special Exempt Income is the cost of certain court ordered payments paid out-of-pocket by the person. The definition of Special Exempt Income is found in the Medicaid Eligibility Handbook Section Special Exempt Income. Special exempt income includes: Income used for supporting others (see Medicaid Eligibility Handbook (MEH) Section ). Expenses associated with a Self-Support Plan (see MEH ). A PASS Plan allows a person set aside money for a specific work goal. This money set aside does not count as income in computing an SSI payment 1Must have income other than SSI (e.g. SSDI, work earnings)2be in writing 3Establish a specific and feasible work goal 4Set up a specific timeframe for reaching the goal 5Plan must be approved and reviewed periodically Impairment Related Work Expenses (see MEH ). Out-of-pocket expenses related to a person s disability AND working. Examples: special equipment, readers, interpreters, attendants, special transportation. The value of an IRWE can help reduce countable income below SGA. An IRWE must be approved by SSA. Costs for a person to temporarily maintain a home or apartment (see MEH ). Costs associated with real property listed for sale (see MEH 16.2). Such as taxes, expenses to maintaining heating, lights, other incurred out of pocket expenses to maintain a property pending its sale. Certain fees to guardians or attorneys (See MEH ) o Not Countable Do not count the following as income available for room and board: 1. Court-ordered guardian and/or attorney fees paid directly out of the person's monthly income. 2. Expenses paid by the person for establishing and maintaining a court-ordered guardianship or protective placement for him/herself. o Countable Do count as income available for room and board any payments a person makes to: 1. A legal guardian or attorney, which are not court-ordered payments. Do not deduct such payments from income considered available to pay room and board. 2. A third party to reimburse a prepayment of a guardianship fee made by the third party. Do not deduct such payments from income considered available to pay room and board. Exception: Deduct this third party prepayment from income considered available to pay room and board if: a. The third party was the county acting as guardian ad litem; and b. The prepayment was to an attorney who was not a county employee at the time the services were delivered; and c. A court ordered the person to reimburse the county's prepayment. Other exempt Income for the purposes of calculating member contribution to R&B: Garnishments deducted from members earned income Deductions from unearned income including IRS and SS paybacks. Special Exempt Income information can be obtained: For Group A, obtain this amount from the participant or IM Worker For Group B, obtain this amount from either the Community Waivers Budget page or the Expenses Summary page in CARES Worker Web. For Impairment Related Work Expenses you can find the information on the Employment Related Work Expense page in CARES Worker Web For Group C, obtain this amount for married individuals from the Expenses Summary page and the Impairment Related Work Expense page in CARES Worker Web For Group C, obtain this amount single from either the Community Waivers Budget page or the Expenses Summary page in CARES Worker Web. For Impairment Related Work Expenses you can find the information on the Employment Related Work Expense page in CARES Worker Web 3

4 19. Verify/Enter Family Maintenance Allowance. Family Maintenance Allowance is the cost of living allowance for maintenance of dependent family members paid out-of-pocket. For Group A, enter $0. Under Spousal Impoverishment Rules, each dependent family member can be allocated a certain amount as a Family Maintenance Allowance. The amount changes yearly in accordance to spousal impoverishment rules. Income that is allocated to a dependent family member doesn t actually have to be given to the family member, but it can be counted as a deduction from income. Dependent family members include: Dependent minor children (natural, adopted, step) of either parent who live with the community spouse. Children (natural, adopted, step), 18 years of age or older, of either parent, who are claimed as dependents for tax purposes under the Service Code Internal Revenue ( IRSC ) and who live with the community spouse. Siblings of either the institutionalized person or the community spouse who are claimed as dependents and who live with the community spouse. Parents of either the institutionalized person or the community spouse who are claimed as dependents and who live with the community spouse. Family Maintenance Allowance information can be found: For Group B or C individuals who are single on the Community Waiver Budget Screen in CARES Worker Web For Group B or C individuals who are married on the Spousal Impoverishment Income Allocation Worksheet, Section B, line Verify/Enter Spousal Income Allocation. Spousal Income Allocation is income the person is allowed to and has chosen to allocate to support her/his spouse and any dependent family members who live in the community (applicable to Group B or C). For Group A, enter $0. More information on Spousal Income Allocation can be found in the Medicaid Eligibility Handbook Section Income that is allocated for the community spouse must actually be given to the community spouse each month, in order for it to be allowed as a spousal income allocation deduction. This information can be obtained from the Spousal Income Allocation Worksheet, Section C, line Verify/Enter Cost Share/Spenddown Cost Share/Spenddown is an amount prior to determining the amount of income an individual has available for the cost of room and board, any income required to be used to establish eligibility (spenddown) or any required post eligibility treatment of income (cost share) must be deducted. This information can be obtained: For Group B, from the Community Waiver Budget page in CARES Worker Web For Group C married, from the Spousal Income Allocation Worksheet, line 11 For Group C single, from Community Waiver Budget page in CARES Worker Web 22. Total Calculated field no entry needed PPS will total the Allowance & Deductions information Cost of Room and Board 23. Cost of Room and Board in This Facility no entry needed. Results 24. Total income available for room and board no entry needed. 25. Total income available to meet deducted cost and for personal use no entry needed. 26. Total cost of room & board no entry needed 27. Total potential room and board subsidy no entry needed 28. Total nursing facility statewide amount no entry needed the 2010 statewide amount is $828/month 29. Potential cost-effective supplementation (supplementation for this individual in this facility). If $0, no room and board supplementation is needed for this member in this facility. If greater than $0, this is the amount of room and board supplementation needed for this member in this facility. The IDT, in accordance with MCO guidelines, must determine whether it is appropriate to use MCO funds to supplement the person s ability to pay for room and board and document its decision in the following section. 4

5 IDT Decision about Supplementation of Room and Board If Total Potential Room and Board Subsidy (line 27) is $0.00, this person has sufficient funds to pay the room and board cost in this facility. If there is an amount for Total Potential Room and Board Subsidy (line 27), that is the amount of room and board the MCO would have to supplement for this person to live in this facility. The IDT must, in accordance with MCO guidelines, determine whether it is appropriate to use MCO funds to supplement this member s ability to pay for room and board at this level in this facility. a. If the IDT decides to supplement the member s ability to pay room and board, document below whether this supplement is a cost-effective substitution for institutional care; include this form in the member s case file: and or i. This person is eligible for, and without room & board supplement is at imminent risk of institutionalization. ii. a) The entire amount of room & board supplement is cost-effective, because the MCO would pay more to supplement room and board in an institution Total Nursing Facility (line 28) statewide amount than the room and board supplement identified for Total Potential Room and Board Subsidy (line 27). ii. b) The amount in Total Potential Room and Board Subsidy (line 27) does not represent the entire room and board supplement the MCO will pay for this individual. Only the Total Nursing Facility statewide amount (line 28) is a cost-effective substitution for institutional care. (See instructions for MCO Fiscal Staff) b. If the IDT decides not to supplement the member s ability to pay room and board, document in the member s MCP/ISP how the member s outcomes will be addressed. 5

6 APPENDIX A: CERTIFICATION OF COST-EFFECTIVENESS OF ROOM AND BOARD SUPPLEMENTATION BY MCO 1. MCO encounter reporting related to room and board in community-based long-term care residential facilities is coded in the LTCare Encounter Reporting Application as: a. MCO paid claims for the cost of room and board in facilities: AFH 1-2 AFH 3-4 CBRF RCAC b. MCO revenues for the cost of room and board in facilities: AFH 1-2 AFH 3-4 CBRF RCAC 2. The MCO asserts and will maintain documentation (on line 26 of this completed form) in each member s record that whenever the MCO pays more in room and board to a facility for any member than it has collected from that member, the resulting supplementation of room and board is a cost-effective substitution for institutional care for that member. 3. The certification of MCO encounter data by the MCO s Chief Financial Officer constitutes certification that the MCO has not reported supplementation of room and board for any member that is not documented in that member s record (on line 26 of this form) as a costeffective substitution for institutional care. CARES Worker Web Access Information and Instructions for MCO Staff: For instructions for accessing CARES Worker Web see: (See also Appendix D Strategies When Members Refuse to Pay Room and Board Obligations.) 6

7 APPENDIX B: PRINCIPLES IN THE TREATMENT OF EXPENDITURES INDIVIDUALS MAY MAKE WHEN DETERMINING INCOME THE MEMBER HAS AVAILABLE TO PAY ROOM AND BOARD IN SUBSTITUTE CARE (CBRF, AFH OR RCAC) 1. Deduct the following costs from income considered available to pay for room and board before the member pays for room and board: a. Costs necessary to maintain or preserve the health or well-being of the member or another person for whom the member is legally responsible These include: Health insurance premiums Cost share or spenddown Medical or remedial expenses Guardian and guardian ad litem fees (court ordered or not) Costs to establish and maintain a guardianship (court ordered or not) Spousal income allocation or other family maintenance allowance (child support) Personal and Clothing Allowance b. Costs necessary to maintain or preserve the income or assets available for support of the member or another person for whom the member is legally responsible These include: Impairment related work expenses Expenses associated with a self-support plan Costs for a person to temporary maintain a home or apartment Costs associated with real property listed for sale 2. Do not deduct other costs from income considered available to pay room and board; they can be paid from the member s income available after paying for room and board. These include: Other attorney fees (court ordered or not) Other costs a member chooses 7

8 APPENDIX C: POLICY RELATED TO PAYMENT OF GUARDIAN FEES AND ROOM AND BOARD FOR PEOPLE WHO LIVE IN SUBSTITUTE CARE (Reserved) DHS is working on a policy and related solutions to funding guardian fees. Until that policy is fully developed, DHS, Counties, ADRCs and MCOs should continue to work together to: Try to recruit more volunteer guardians Work with courts to understand the limited funds individuals have to pay guardian fees, Work with corporate, volunteer and family guardians to keep fees reasonable. Use guardianships only when needed by relying on alternative approaches, such as power of attorney for health care, where possible. 8

9 APPENDIX D: STRATEGIES WHEN MEMBERS REFUSE TO PAY ROOM AND BOARD OBLIGATIONS Issue: MCOs are seeking standardized strategies for how to proceed when members refuse to pay room and board obligations. When members refuse to pay cost share or patient liability obligations they risk loss of FC eligibility, while payment of room and board is not required to maintain eligibility. Without the threat of disenrollment MCOs, which pay providers full daily rates expecting to collect room and board from members MCOs are caught in the middle when members fails to pay their room and board. The strategies identified below assume the MCO has thoroughly assessed any coercion by others, diminished capacity, stress or other factors that may be contributing factors in members not meeting their room and board obligations. The MCO Room and Board Workgroup discussed the following strategies: 1. Educate members at the time of enrollment or residential placement of room and board obligation. 2. Consider having members sign a statement acknowledging that they have been informed of this obligation, and the potential consequences of failure to pay (see strategies below). 3. Monitor and notify members in writing immediately if payment is not received at due date. (the longer you wait the less likely the member will retain the funds i.e. spent on other things) 4. Follow up written notification letter above with a phone call. Consider who within MCO organization is most likely to assist member in understanding this responsibility. 5. In communications to members consider the following responses for failure to pay: a. Consider referral to APS if there are potential abuse or neglect issues related to non payment. Issues could include self neglect if the member is her/his own decision maker or misappropriation if it is an alternate decision maker choosing not to pay. b. Seek representative payee, guardian of estate or limited guardianship based on the member s failure to meet her/his own basic needs for members that are their own decision maker for financial resources. (May ask for assistance with APS and/or member physician) c. Seek change in rep payee, guardian or other alternate decision maker when the member s finances are managed by someone other than member who is choosing not to pay room and board. (May ask for assistance with APS) d. Alert ES to the potential need to review assets limits. e. Involve residential provider - MCO consider not paying room and board rate to facility and collaboration with facility to initiate discharge for failure to pay room and board. 6. Submit to collection agency. 9

10 APPENDIX E: MEDICAL REMEDIAL EXPENSES FREQUENTLY ASKED QUESTIONS Definition of Medical and Remedial Expenses (MRE): Medical expenses are expenses for services or goods that have been prescribed or provided by a professional medical practitioner. The expense is for diagnosis, cure, treatment, or prevention of disease or for treatment affecting any part of the body. These are expenses that are the responsibility of the member, and cannot be reimbursable by any other source, such as Medicaid, Family Care, private insurance, or employer. Medical expenses must be paid out-of-pocket by the person. The following are examples (not an all-inclusive list) of medical expenses: Deductibles and co-payments for Medicaid, Medicare, and private health insurances Bills for medical services which are not covered by Medicare, Medicaid, FC, or other insurance Medical services received before the person became eligible for Medicaid/ FC, which the person is making payments on. Remedial expenses are costs incurred for services or goods that are provided for the purpose of relieving, remedying, or reducing a medical or health condition. These are expenses that are the responsibility of the member and cannot be reimbursed by another source, such as Medicaid, Family Care, private insurance or employer. If an item can be covered in the Family Care, Partnership or benefit and is identified as a service necessary to achieve an outcome, then the MCO should provide it. If a service is denied by the MCO, the member must be provided with a notice of action in accordance with contract requirements in relation to service authorization decisions that deny or limit a requested service. The member has a right to appeal that decision. Information about member appeal and grievance rights is available from the MCO. Services that are part of the FC and/or FCP benefit package are not remedial expenses. A vendor s refusal to accept MA is not cause for inclusion of an item as a MRE. Frequently Asked Questions and Answers on Medical and Remedial Expense 1. Many Medicaid services have co-payments amounts. Can payment of co-pays be considered a medical expense? Yes. Any co-payment that a member makes is allowable as a medical expense. Reminder: There are no co-pays for services in the Family Care benefit package. 2. What types of medical bills may not be used as a medical/remedial expense? The following bills and/or payments on these types of bills cannot be counted as a MRE: 10

11 From DLTC Memo Series Medical bills which remain unpaid, but were previously used to meet a Medicaid deductible; Bills which were for the cost of institutional care provided during a previous Medicaid divestment penalty period; Bills that represent a patient liability amount or cost share incurred during some previous period of institutionalization and Medicaid eligibility, or, an unpaid Family Care cost share obligation; Medical bills which will be paid by a legally liable third party, e.g. private health insurance, Medicare, Medicaid, etc. Medical bills which were previously allowed as a medical/remedial expense and counted to reduce a family care cost share or used to reduce a nursing home patient liability obligation. 3. What unpaid medical bills can be counted as medical expenses? Notwithstanding exclusions noted in #2, outstanding medical bill must have been incurred by the member and the member must actually be making monthly payments to the medical provider to count as a medical expenses. 4. What if the unpaid bills (that the individual is making payments on) have already been used to meet a deductible? Can payments be used as medical expenses for the Family Care program? No. As stated in DLTC Memo Series , there are certain unpaid bills that the member may still be making payments on, but are not permissible as a medical/remedial expense. Such is the case for bills which were previously used to meet a Medicaid deductible. 5. Can you count a widow s payment on her deceased husband s medical debt as a medical expense for someone who is applying for the Family Care program? This expense is allowable when meeting a deductible. No, this is not an allowable medical or remedial expense for the Family Care program. This is a personal debt. It is not her medical debt. Unlike the Medicaid deductible program, under the Family Care program we consider the individual, not the fiscal group when determining medical/remedial expenses. However, it is possible for the IM worker to simultaneously screen an applicant/member under the Medicaid deductible program to see if a medical bill for a member of the fiscal group can be considered under that program. 6. Can the cost of a member s prescription medications be counted as a medical expense? In Family Care, this would be very unusual. However, if the member s Medicare Part D plan, Medicaid, or private insurance does not cover a medicine that has been prescribed by the member s physician, for medications that require a prescription, and the member pays for the medication out of pocket, then the expense can be used as a medical/remedial expense. See Question 11 below for examples of over the counter medications. 11

12 In Partnership No. medications that require a prescription and prescribed would always be in the Partnership benefit package 7. Can a recipient s payment for a life insurance policy be used as a remedial expense? No. Life insurance policies benefit the estate and/or any surviving family members. 8. Can the cost of long distance calls to providers be counted as a remedial expense? No. the cost of phone services is an individual s obligation. Most phone plans include local and long distance calls as part of basic service and/or many health care systems and providers have toll free numbers, subsequently the need for members to incur long distance charges to providers is unnecessary. 9. Can the cost of basic landline phone service be a remedial expense for a member who utilizing a PERS? Only if all the following conditions are met: a member does not otherwise have a landline phone. a PERS is required to meet the health and safety needs of a member, and The phone is in the members name and their obligation In establishing this intervention, IDTs will need to consider the cost effectiveness of a PERS when necessitating a phone line. If the member does not have a PERS, the cost of the phone line cannot be counted as a remedial expense. If a member already has a phone, the cost of the phone line cannot be counted as a remedial expense. 10. Can the cost of a cellular telephone service for a member be a remedial expense for a member? No. If a member chooses a cell phone in addition to or in replace of a land line phone these costs are the responsibility of the member. In some cases a cell phone may be FC/FCP benefit service if it meets the definition of a PERS. In these instances the cell phone is still not a MRE; it is a FC benefit services authorized to meet the needs of a PERS. 11. Can the cost of food ever be considered a medical/remedial expense? Yes, Exceptional food costs due to a special condition and in excess of what a nutritional diet would include may be considered medical/remedial expense. 12

13 Services That Are Part of the Family Care Benefit Package Any service in the program benefit package (FC/ FC P) is either authorized via the RAD by the IDT or denied via the RAD by the IDT. Services denied in the RAD cannot be then counted as medical or remedial expenses. If an IDT denies authorization of an item that is in the benefit package that a member is currently paying for as a medical/remedial expense, the IDT should provide the member with a notice of action in accordance with contract requirements in relation to service authorization decisions that deny or limit a requested service. Denials of requests for services are subject to Notice of Action and Appeals and Grievances. Outlined in this section are common examples of expenses that may historically have been counted as MRE. All of them are in the FC or FC P benefit packages. As IDTs review MRE for individuals enrolling in FC or FCP, the costs below may have been incurred by the individual in other programs (COP or CIP). In FC/ FCP these services are in the benefit packages. While a member may still choose to purchase items or services that are not authorized as a part of the MCO care plan those expenses cannot be counted as medical or remedial deduction for the purposes of calculating member cost share or contribution to room and board. IDTs should review the MCOs policy on member use of personal resources for further direction on how to proceed when members choose services in excess of authorized items or services. 12. A member requests an item or service that is covered in the benefit package. However, when the IDT completes the RAD process, it is determined the Family Care benefit will not fund the item. The member still wants to purchase the item or service and is willing to pay for it. Can the cost of an item or service be counted as a medical/remedial expense? No. Items or services that are in the Family Care benefit plan are either authorized by the IDT and funded by the MCO or denied via the Resource Allocation Decision Method. 13. A member has a prescription for an over the counter medication, can the IDT count the cost of this OTC as a medical remedial expenses even if the RAD process results in not authorizing the OTC? No. OTCs are part of the FC benefit plan and are either authorized by the IDT and funded by the MCO or denied via the RAD. A prescription for an OTC does not change this process. The IDT may also want to coordinate with the prescription physician to discuss the situation. 14. Can the cost of a brand name be counted as medical remedial? A member needs to take an aspirin a day. The team gets confirmation this is appropriate. The MD indicates the member can take a generic brand of aspirin. However, the member s preference is to take Bayer. The member says he is willing to pay for the Bayer and wants to count that cost as a medical/remedial expense. No. The requested OTC is a Family Care benefit and the MCO is willing to pay for it. There is no medical reason a generic product cannot be used. If the member does not want the generic brand, then he is making a choice to purchase the name brand and this cost cannot be counted as a medical/remedial expense. 13

14 15. Can the member pay the difference between the brand name product and generic brand and count that difference in cost as a medical/remedial expense? A member needs to take an aspirin a day? If a member requests an OTC and the team applies RAD and it is determined to be an appropriate means of meeting the member s outcome and it is cost effective, but the member request a specific brand of product. The team gets confirmation this is appropriate. The MD indicates the member can take a generic brand of aspirin. However, the member s preference is to take Bayer. The member says he is willing to pay for the Bayer. If the cost of generic is $4.00/bottle and Bayer is $6.50 he wants to count the difference between these two costs $2.50 as a medical/remedial expense. No. The requested OTC is a Family Care benefit and the MCO is willing to pay for it. There is no medical reason a generic product cannot be used. If the member does not want the generic brand, then he is making a choice to purchase the name brand and this cost (even the cost difference between the two) cannot be counted as a medical/remedial expense. 16. Can a member privately pay a neighbor or family member for lawn care or snow shoveling, and count that cost as a medical/remedial expense? No. Items or services that are in the Family Care benefit plan are either authorized by the IDT and funded by the MCO or denied via the Resource Allocation Decision Method. 17. Can a member privately pay a neighbor or family member for assisting with supportive home care or grocery shopping, etc., and count that cost as a medical/remedial expense? No. Items or services that are in the Family Care benefit plan are either authorized by the IDT and funded by the MCO or denied via the Resource Allocation Decision Method 18. A member purchases various herbs, minerals, and other alternative remedies (shark cartilage, bee pollen, St. John s Wort, blue-green algae, etc) for their long term physical illness and/or disability. Can these out of pocket expenses be counted as a medical/remedial expense? No. Items or services that are in the Family Care benefit plan are either authorized by the IDT and funded by the MCO or denied via the Resource Allocation Decision Method. 19. Can a member supplement the wages of his/her supportive home care worker or personal care worker (who is funded by the Family Care benefit), and count that supplementation as a medical/remedial expense? No. Supplementing the worker s wage cannot be used as a medical/remedial expense because it is prohibited under Medicaid and Family Care rules. 14

15 Transportation Medical and non-medical transportation is part of the Family Care benefit package. Common carrier and County income maintenance (IM) reimburse for medical transportation remains fee for service. (Common carrier pending inclusion in FC benefit 1/2011*). When common carrier becomes part of the FC benefit the responses below indicating IM funding will be replaced with these services are in the FC benefit and subject to RAD. In Family Care Partnership, all transportation resources noted above, plus ambulance are the responsibility of the FC-P program. 20. If a member pays a family member or neighbor to provide medical transportation can this be counted as a medical/remedial expense? No. Transportation provided by an informal support as described above may be subject to reimbursement via the county IM department but it is not a remedial expense Also, medical transportation is part of the FC benefit package and items or services that are in the Family Care benefit plan are either authorized by the IDT and funded by the MCO or denied via the Resource Allocation Decision Method. 21. If a member pays a family member, neighbor, friend, etc to provide transportation for any non-medical trips in either the member s own vehicle, or in the vehicle of the family member, neighbor, friend, can this be counted as a medical/remedial expense? No. Items or services that are in the Family Care benefit plan are either authorized by the IDT and funded by the MCO or denied via the Resource Allocation Decision Method. This service may be funded via SDS. The cost cannot be counted as a medical remedial expense. 22. If a member provides his/her own transportation for any non-medical trips in his/her own vehicle can this be counted as a medical/remedial expense? No. Items or services that are in the Family Care benefit plan are either authorized by the IDT and funded by the MCO or denied via the Resource Allocation Decision Method. Non medical transportation is part of the FC benefit. MCOs don t reimburse members or authorize members as providers of services. In instances where members provide their own transportation, it may be appropriate for the IDT to authorize gas cards. The cost cannot be counted as a medical remedial expense. 23. If a member provides his/her own medical transportation in his/her own vehicle can this be counted as a medical/remedial expense? No. A member can be reimbursed for his/her medical mileage through the county s local Income Maintenance Unit. 15

16 Other Services 24. Can a care manager assign a value for the assistance that a spouse provides to the member and count that assigned dollar amount as a remedial expense? No. The Family Care benefit does allow payments to spouses for services provided to a member if certain criteria are met. As a result, it is not allowable to count an assigned value for assistance provided as a remedial expense. 25. What expenses may be counted as remedial expenses when a member has a live-in attendant? In most cases, the cost of housing for a live-in attendant is not considered a medical/remedial expense. Generally housing costs are considered part of the special housing amount, which is a component of the personal maintenance allowance. However, there are some exceptions. For Group B members, when housing costs exceed the personal maintenance maximum and the member is paying for all of his/her own room and board costs and for all of the room and board costs of the live-in attendant, the difference between the special housing amount and the maximum personal maintenance allowance may be counted as a remedial expense. In addition, a live-in attendant s food and incidental household supplies (for example: toilet paper, laundry soap, etc.) if paid in full by the member, can be counted as remedial expenses and recorded on the medical/remedial line of the CWB page. Note: the wages for a live-in attendant are a Family Care benefit and must not be considered a remedial expense. Example involving Group B member with a live-in attendant Group B single Family Care member Janet Murphy, needs and has a live-in attendant. The attendant does not pay any costs towards the rent, heat, utilities, food, and incidental costs involving a household. The member pays for all these costs in full. The attendant is paid for the assistance she provides to the member by Family Care/Partnership funds. The member s monthly costs are: $700/month - (she rents a 2 bedroom apt. to accommodate the live-in attendant.) $100/month - heat $ 80/month - utilities $400/month for food (both share this food but member pays entire costs) $10/month incidental costs (toilet paper, paper towels, laundry soap, etc. that member pays entire cost) Because Ms. Murphy is Group B eligible, she is eligible to have the Special Housing Amount deduction considered. The IM worker will look at the housing costs associated with rent, heat, and utilities. The expenses: $ = $880.00/month. 16

17 Because this dollar amount exceeds $350/month, CARES will determine Ms. Murphy is entitled to the Special Housing Amount deduction and the amount that will be seen on CARES CWB is $530. ($880 - $350 = $530). That is why it is incorrect to include housing costs involving rent/mortgage, heat, utilities as a medical/remedial expense. The IM worker enters these costs in the Shelter screens of CARES and the resulting figure is shown as a Special Housing Amt deduction on the CWB. However, regarding the food and incidental costs: because the member is paying for these costs in full, the care manager could consider $ as a medical/remedial expense. This amount is calculated as follows: $ = $410. $400 divided by 2 = $ Note: in the event the live-in attendant contributed towards the cost of food and incidentals, it would not be allowable to count these costs as a medical/remedial expense for the member. Example involving Group C single member with a live-in attendant For single Group C members, the food and incidental household supplies (for example: toilet paper, laundry soap, etc.) of a live-in attendant can be considered remedial expenses and can be used to meet the spenddown, as long as the Group C member is paying for these expenses in full. In addition, certain housing costs paid by the Group C member, when necessitated by having a live-in attendant (e.g. the difference in cost between a one-bedroom and two-bedroom apartment, half of the basic telephone and utility bills) can be counted as medical and remedial expenses. All of these are recorded as medical/remedial expenses on the CWB page because there is no other area to count these costs on the CWB for a Group C single member. Group C single Family Care member Steve Jackson, needs and has a live-in attendant. The cost of a one-bedroom apartment is $500/month and the cost of a two-bedroom apartment is $800/month. Steve needs a two-bedroom apartment to accommodate his live-in attendant. Steve pays the full $800 rent with his funds alone. In addition, the monthly basic phone is $28/month and the utility bill averages $60/month. Steve pays for these costs with his funds alone also. What can the care manager count as remedial expenses for Mr. Jackson? Because Mr. Jackson pays these costs in full with his funds alone the care manager uses the expenses necessitated by a live-in attendant, as follows: $300 (difference between a 1-bedroom apartment and 2-bedroom apartment) $ 14 for the telephone costs (half of $28) $ 30 for utilities (half of $60) $344 Total As a result, the care manager would be able to use $344 as a remedial expense for Mr. Jackson. 17

18 Calculating Medical and Remedial Expense 26. Can a projection of anticipated but undetermined medical bills be counted as a medical expense? No. Medical/remedial expenses can only reflect actual monthly payments made on a procedure that has occurred. MRE deductions may not include deductions for saving up in consideration of projected future procedures. 27. If the participant received a cash advance from a credit card company or took out a second mortgage to pay off his/her own medical bills, or charged his/her clinic visits to a credit card; or paid for a piece of medical equipment with a credit card and is now paying off these expense on his/her own credit card - can this monthly payments to the credit card company or bank be considered a medical expense? If these debts do not fall under one of the five types of bills not allowed in #2 definitions and if these debts meet the criteria enumerated below, then the answer is yes. These criteria include: the service/item purchased was a legitimate medical/remedial expense for the applicant/member, the charges were for services/items that would qualify as an allowable medical/remedial expense or as an allowable Family Care item or service, and the original invoice/receipt or a copy of the original invoice/receipt can be obtained to confirm both the date and that the service/item was obtained. 28. If an average was used when paying off a medical bill that the IM worker confirmed was an allowable/acceptable medical expense and then the member makes a lump sum payment towards that medical bill thereby paying off the bill, does the average medical and remedial expense need to be recalculated? Does a new Community Waiver Budget (CWB) screen page need to be generated based on this change in medical/remedial expenses? Yes. If the member paid off a medical bill that was to have been paid in monthly installments, the expense cannot continue to be averaged throughout the remainder of the year. The lump sum payment can only be counted as a medical and remedial expense in the month that it was paid. The care manager is required to inform the Income Maintenance worker that medical and remedial expenses have changed and the CWB page needs to be recalculated for the member. 29. If a lump sum payment was made before a person became Family Care eligible, can this be used to reduce the cost share? No. Medical and remedial expenses are meant to represent an estimate of future expenses that the member will pay over the next twelve months. If an applicant paid off a $3,000 medical bill one month before starting on the Family Care program, the amount of the payment cannot be applied toward the cost share deduction because the debt was eliminated before the cost share obligation was established. However, note that this medical/remedial expense may be used by the IM worker to establish Medicaid eligibility under the Medicaid deductible program. 18

19 30. How does CARES recognize two different medical/remedial expenses? This is problematic when dealing with a married Group C participant and spousal impoverishment rules apply and we are trying to determine the correct cost share amount. How do we do this? This information is captured on several separate CARES screens the ANCW, ANFR. and the AFME. The information below is for a Group C Married Applicant only CWB The medical/remedial expenses include both expenses that are actually paid by the individual applying for Family Care as well as expenses the individual incurs and will be funded by the Family Care benefit. The Medicaid card coverable expenses are expenses that the applicant will be receiving and funded by Medicaid if found eligible for Family Care. The Medicaid card coverable expenses reflect what Medicaid reimburses the provider. The ANCW screen has both the medical/remedial and the Medicaid card coverable expense amounts that have been entered by the eligibility worker from the information provided by the ADRC or IDT The total of both the incurred expenses and expenses that are actually paid by the individual (medical/remedial and Medicaid card coverable expenses) are used to reduce the countable net income to the medically needy income limit. If that occurs, the individual is eligible for Family Care. The spenddown amount is the difference between the countable net income amount minus the medically needy income limit. Important note for Group C married individuals On the CARES Worker Web (CWW) even though the budgets have moved to CWW, the logic has not. IM workers should be doing what has been done in the past per MEH : Complete a manual Spousal Impoverishment Income Allocation Worksheet (40.2 WKST 07) for any spousal impoverishment case that is Group C eligible. Send a copy of this completed worksheet to the care manager. 19

20 Verification, Documentation, & Monitoring of Medical and Remedial Expenses MCOs must establish processes within their organizations for verification, documentation and monitoring of medical/remedial expenses. Those processes must meet the following criteria: 1. Be in compliance with instructions and information contained in this FAQ 2. Be documented in a way that can be reviewed 3. Illustrate monitoring in compliance with criteria set forth in this document. The information below will be modified by MCOs to reflect these criteria. 1. Can the care manager do a verbal review of medical and remedial expenses? MCOs should establish a policy and procedure on verification of MREs. 2. How far should the care manager go to verify payment of medical and remedial expenses? The system or level of verification used should be tailored to the member. Some people are very aware of the cost of items they routinely use and they know where every dollar of their budget goes. Other people are less aware of their routine expenses and don t keep receipts. One option is to ask the member to save his or her receipts and review them regularly with you. Other options could include reviewing the member s checkbook ledger, canceled checks, money order receipts, and other receipts or billing statements that list past payments made on the account. It is good practice to check the original medical and remedial estimates for accuracy at regular intervals with the member. 3. If an individual has difficulty keeping a paper trail that verifies expenses are incurred and paid, what might the care manager do to monitor or determine expenses? (This assumes the person is not incompetent or a candidate for guardianship.) If the member has difficulty keeping accurate records you might do the following: Ask the member to keep his or her receipts for medical and remedial expenses in a designated place like an envelope, a shoebox, or a drawer. Ask the member s support staff to shop with the member and collect the receipts for medical and remedial items purchases. If receipts aren t available you could do the following: Ask the member what medical and remedial expenses he/she regularly incurs and pays for, then verify the costs. Ask member s in-home caregivers what over-the-counter medications and/or supplies the member uses and how frequently. Ask someone who shops for/with the member what over-the-counter medications and/or supplies they purchase and how often they do so. Request a printout of the pharmacy s customer profile listing prescribed medications, what Medicaid pays, what Medicaid doesn t pay, and the customer s co-pay. 20