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Effective: December 1, 2007 |
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03.40.15ar2 - Developmental Disabilities (DD) (Archive) |
Archived: July 1, 2008 |
Certain people with developmental disabilities (DD) who are eligible for Medical Assistance (MA) may be eligible for additional home and community-based services if they:
l Use a disabled basis of eligibility for MA.
l Require a 24-hour plan of care.
l Choose to participate in the waiver program as an alternative to receiving care in an Intermediate Care Facility for Persons with Mental Retardation or Related Conditions (ICF/MR).
There is no age limit for the Development Disabilities waiver (formerly known as the Mental Retardation and Related Conditions waiver).
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 earliest possible begin date of MA without deeming parental or spousal income is the first day of the month in which waiver services are anticipated to begin.
Note: Waiver services cannot begin before the date a person is determined to be eligible for MA payment of LTC services.
Renewals (standard guidelines)
Follow standard MA guidelines.
The county case manager determines that the person has a diagnosis of mental retardation or a related condition and requires a 24-hour plan of care. DD does not require that the person be certified disabled by the Social Security Administration (SSA) or State Medical Review Team (SMRT) . The case manager’s waiver determination takes the place of the MA disability certification.
Note: This includes people who receive MA for Employed Persons with Disabilities (MA-EPD) concurrently with DD.
Social Security Number (standard guidelines)
Follow standard MA guidelines.
Follow standard MA guidelines.
Residency (standard guidelines)
Follow standard MA guidelines.
DD 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-EPD.
Note: MA-EPD enrollees must have income under 200% FPG to qualify for payment or reimbursement of Medicare premiums.
Household Composition (standard guidelines)
Determine whether the person is eligible for MA based on income and assets. Beginning with the month in which DD waiver services are anticipated to begin:
l Do not deem the income of the spouse or parents. Count the income of the DD client only.
l Use a household size of one.
Parents of children who receive services through the DD waiver may be required to pay a parental fee. To determine if a parental fee is required:
l If the parents report income orally or on the HCAPP that is less than the MA standard for the household size:
n Request verification of the parents' income.
n Determine eligibility based on the household size.
n If the eligibility determination using the parents' income results in no spenddown for the child, a parental fee is not required.
l If the parents report income orally or on the HCAPP that would result in the child having a spenddown:
n Do not request verification of the parents' income.
n Send a referral to the DHS Parental Fee unit based on the parents’ statement for any child under age 18. Parental fees are not required for children ages 18 or older.
Note: Parental income is not counted for children under age 18 who receive adoption assistance or Supplemental Security Income (SSI). For these children under age 18 who receive:
m Adoption assistance - Send a referral to the DHS Parental Fee unit. Note that they receive adoption assistance 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.
m SSI - Do not send a parental fee referral.
If the person is requesting retroactive MA for months before DD services begin, follow standard MA household size and deeming guidelines for the retroactive months.
If eligibility for the Medicare Savings Programs is also being determined, follow the household size and deeming guidelines of the Medicare Savings Program for that program's eligibility.
Eligibility Method (standard guidelines)
Use Method B for assets and income.
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.
DD applicants and enrollees may transfer assets to their spouses without penalty. Asset transfers to others must be evaluated to determine if they were uncompensated. Uncompensated transfers may result in a penalty period during which the client is ineligible for DD waiver services.
Income Guidelines (standard guidelines)
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.
Follow standard MA guidelines.
Spenddowns/Premiums (standard guidelines)
If income is greater than 100% FPG, the person must spend down to 75% FPG. Use a monthly spenddown. Treat the cost of waiver services as a medical bill incurred on the first of the month. The DD 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)
DD funds the following services in addition to the standard MA services:
l Day training and habilitation services, including supported employment.
l Supported living services for children.
l Supported living services for adults.
l Respite care.
l Homemaker services.
l Environmental modification.
l Case management.
l In home family supports.
l Adult day care, including bath.
l Extended personal care attendant services after regular MA coverage is exhausted.
l Personal support.
l Assistive technology.
l Caregiver and consumer training and education.
l Chore services.
l Specialist services.
l 24-hour emergency assistance.
l Consumer directed community services (CDCS).
l Housing access coordination.
l Transportation.
l Crisis respite.
l Transitional services.
l Home-delivered meals.
DD services are not available during a period of hospitalization or residence in an ICF/MR or nursing facility.
Service Delivery (standard guidelines)
Enrollees age 65 or older must enroll in managed care if they live in managed care counties. For more information, see Managed Care Delivery Systems.
The average statewide cost to MA for DD services must be less than the cost of providing the care in institutional settings. DHS makes this determination by averaging the cost of services for all eligible people. This cost requirement does not apply to each individual who receives DD services.
Follow standard MA guidelines.
DD enrollees who apply for Medicare Savings Programs must meet all requirements for those programs. Refer to the guidelines noted earlier in this section.
Children who do not require the additional services provided by the DD waiver may be eligible under TEFRA.
Not applicable.