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Effective: December 1, 2006 |
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03.40.05ar1 - Community Alternative Care (CAC) (Archive) |
Archived: July 1, 2008 |
Community Alternative Care (CAC) is a federally approved home- and community-based services waiver program for chronically ill people who are eligible for Medical Assistance (MA) and:
l Have a disabled basis of eligibility.
l Are under age 65 at the time of screening.
Note: People who turn age 65 after the CAC screening may remain on CAC if the case manager determines their needs cannot be met through other programs (such as Elderly Waiver).
l Would require frequent or continuous hospitalization over a 12-month period if not for the provision of waiver services.
l Have an interdisciplinary team assessment which recommends waiver services based on the person’s anticipated need for frequent or continuous hospitalization. The county case manager is responsible for obtaining the assessment.
l Have a cost to MA for community-based services that does not exceed the cost of hospital placement based on Diagnostic Rate Group (DRG) charges.
l Choose home- and community-based services.
Eligibility factors are listed below with any information that is unique for this group. Links to standard program guidelines are included as well.
Citizenship/Immigration Status.
Insurance and Benefit Recovery.
Relationship to Other Groups/Bases.
Other Groups/Bases to Consider.
Application Process (standard guidelines)
Follow standard MA guidelines.
The date of the interdisciplinary team assessment and approval is the earliest possible date of CAC eligibility. Coordinate the MA/CAC determination with the case manager.
Renewals (standard guidelines)
Follow standard MA guidelines.
Disability must be certified by the State Medical Review Team (SMRT) or the Social Security Administration (SSA) . Do not refer CAC applicants/enrollees who are certified disabled by SSA to SMRT.
Verify that the county case manager has determined the person to be CAC-eligible through developing a service plan that ensures the person’s health and safety, and completed a cost determination. The recommendation and plan must be approved by DHS.
Social Security Number (standard guidelines)
Follow standard MA guidelines.
Follow standard MA guidelines.
Residency (standard guidelines)
Follow standard MA guidelines.
CAC enrollees who are not eligible for the Medicare Savings Programs are not eligible for payment or reimbursement of Medicare premiums unless they also receive MA for Employed Persons with Disabilities (MA-EPD).
Note: MA-EPD enrollees must have income under 200% FPG to qualify for payment or reimbursement of Medicare premiums.
Household Composition (standard guidelines)
MA eligibility is determined using only the person's own income and assets (household size of one) for all months in which the applicant/enrollee receives CAC services.
l If the person is requesting retroactive MA for months before CAC services begin, follow standard MA household size and deeming guidelines.
l For Medicare Savings Program eligibility, follow the household size and deeming guidelines of the Medicare Savings Program.
Example:
Simon is a disabled adult who is applying for MA under the CAC waiver. He is also eligible for Medicare. His income meets the income standard for CAC and QMB. However, when his wife’s income is deemed to him, their combined income is over the standard.
Action:
Because his wife’s income must be deemed to him under QMB program guidelines, deny QMB for Simon. However, because only his income is used to determine his MA eligibility under the CAC waiver, he is under the income standard for that program. Approve CAC for Simon.
Use Method B for assets and income.
Asset Guidelines (standard guidelines)
Asset limit is $3000 (household size of one), except for:
l Children under 21, who have no asset limit.
l Adults who are concurrently eligible for MA-EPD; then follow the MA-EPD asset guidelines.
Note: When eligibility for a Medicare Savings Programs is also being determined, follow that program’s asset guidelines for the Medicare Savings Program eligibility.
CAC applicants and enrollees may transfer assets to their spouses without penalty. Asset transfers to others may be improper, and result in a period during which the client is still eligible for MA, but ineligible for CAC waiver services.
Income standard is 100% FPG.
Exception: If concurrently eligible for MA-EPD, there is no separate income limit. Follow MA-EPD income guidelines.
Exclude child support and RSDI payments received by or on behalf of children under age 18.
Deductions/Disregards (standard guidelines)
Follow standard MA guidelines.
If income is greater than 100% FPG, the person must spend down to 75% FPG. Use a monthly spenddown. Treat the projected amount of CAC services for the month as a medical bill incurred on the first of the month. The CAC enrollee is responsible for payment of the spenddown amount.
Exception: If the person is concurrently eligible for MA-EPD, follow MA-EPD rules to determine the premium amount.
Covered Services (standard guidelines)
CAC funds the following services in addition to the standard MA services:
l Case management.
l Environmental adaptations and modifications.
l Family counseling and training.
l Foster care.
l Homemaker services.
l Respite care.
l Extended coverage of certain normally covered MA services, such as home health care, personal care attendant services, physical, occupational, respiratory, and speech therapies, prescription drugs, and transportation.
Note: These services are available through CAC only after regular MA services are exhausted.
CAC services are not available during periods of hospitalization.
Service Delivery (standard guidelines)
Enrollees age 65 or older must enroll in managed care if they live in managed care counties.
Refer CAC enrollees under age 18 to DHS to determine and collect parental fees.
Note: If the child receives adoption assistance, either note that on the referral form or notify the DHS Parental Fee unit by other means. Parents of children who receive adoption assistance are not liable for parental fees.
Follow standard MA guidelines.
CAC enrollees who apply for Medicare Savings Programs must meet all requirements for those programs. Refer to the guidelines noted earlier in this section.
Not applicable.