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Effective: December 1, 2006 |
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23.05ar1 - Elderly Waiver (EW) (Archive) |
Archived: August 1, 2007 |
The Elderly Waiver (EW) provides MA funding for home and community-based services for people age 65 and older who would otherwise need nursing facility care. For a list of conditions required to be eligible for EW and a list of services covered by EW, see Long-Term Care and Elderly Waiver.
EW Client Cost Sharing Requirements.
Special Income Standard (SIS).
EW Client Cost Sharing Requirements
EW clients with income equal to or below the Special Income Standard (SIS) amount are eligible for MA without a spenddown.
l These clients are referred to as SIS-EW.
l A waiver obligation may be required to cover the cost of EW services.
The waiver obligation is the amount of income over the maintenance needs allowance and other applicable deductions.
EW clients with income above the SIS amount may have one of the following cost sharing methods:
l Have a medical spenddown.
Note: Treat the projected amount of EW services for the month as a medical bill incurred on the first day of the month for EW clients who have a medical spenddown.
EW clients who may have a medical spenddown:
n Are single (no community spouse).
n Have a spouse also receiving EW services.
l Have a LTC spenddown. EW clients who may have a LTC spenddown are those that have a community spouse who is not receiving EW services.
l Have a Combination LTC/Medical Spenddown. EW clients whose income exceeds the monthly EW charges have a combination spenddown.
The SIS is an income standard equal to three times the Federal Benefit Rate (FBR). It is used to determine whether a client is eligible for SIS-EW.
Follow these steps to determine if an EW client is at or below the SIS.
1. Total all gross earned, gross unearned income and net self-employment income of the client. Do not include the following income:
l A spouse’s income.
l Income tax refunds.
l Property tax refunds, both homeowner’s and renter’s.
l Earned Income Credit (EIC) .
2. Compare the client’s gross income to the SIS.
l A client with income at or below the SIS is SIS-EW eligible.
l A client with income greater than the SIS is EW eligible.
The SIS is updated annually in January. See Special Income Standard (SIS) for exact figures.
EW enrollees may choose to participate in the Minnesota Senior Health Option (MSHO). Health plan care coordinators, county case managers and workers are responsible to communicate with one another regarding the opening or closing of both EW and MSHO to ensure updated coverage for clients.
There are specific rules about when a client must be on EW when home and community-based services are needed, and when they can choose Alternative Care (AC) instead of EW.
Note: Alternative Care is a program funded by Social Services which provides home and community-based services for a person age 65 or older who would otherwise require care in a nursing facility. The client must appear to be eligible for MA within 180 days of receipt of AC services to qualify. See Other Related Programs – Medical Needs for more detailed information on this program.
The following EW clients may not choose AC services over EW services:
l EW clients who are eligible for MA without a spenddown.
l EW clients with income at or below 120% FPG.
Note: These SIS-EW clients may receive AC for up to 60 days while MA eligibility is being determined. The waiver obligation begins and AC ends the first full month SIS-EW services are received.
Example:
Marge requests home and community-based services beginning in January. She applies for MA on January 15 and requests retroactive coverage for November and December. Her assets are within the MA asset limit and her income is less than 120% FPG.
Action:
Marge does not have a choice between receiving AC or EW. She is required to have EW coverage if she wants home and community-based services. Marge may receive AC for up to 60 days while the MA is pending. The AC will end after 60 days or when SIS-EW is approved, whichever is earlier.
The following clients may choose AC over EW if they are within MA asset limits:
l EW clients whose income is greater than 120% FPG for a household size of one but equal to or less than the SIS may choose to receive services through the Alternative Care (AC) program rather than through EW, if they meet the eligibility requirements for AC.
n Help the client determine the difference in cost-sharing obligations between programs, such as the amount of a waiver obligation compared to the AC premium amount.
n If this client chooses AC, they are not eligible for MA with a spenddown.
Exception: If people choose AC and later apply for EW, AC may remain open while the MA application is processed. The applicant may use AC expenses to meet a spenddown during the retroactive period and the processing period. Once SIS-EW is approved, the enrollee will have a waiver obligation.
Example:
Bob has been receiving AC services for 12 months. He applies for MA on April 5 and is requesting coverage back to February. His assets are within MA asset limits and his income is greater than 120% FPG but less than the SIS.
Action:
Determine Bob’s MA eligibility. MA eligibility for February, March and April will be determined with a medical spenddown. Determine Bob’s cost sharing obligations for SIS-EW and compare it to the cost sharing obligation for AC and allow Bob to choose AC or EW.
Bob has a monthly medical spenddown of $300 for February through April. He is able to meet his spenddown with his AC costs and $400 of monthly prescription costs. His SIS-EW waiver obligation is $80.
Action:
The worker informs Bob that he may choose either AC or EW, but if he chooses AC he will no longer be eligible for MA with a spenddown and will be responsible for all of his drug costs.
Bob chooses to begin receiving his services through SIS-EW.
Action:
Approve Bob with a medical spenddown for February through April. Bob can use expenses paid by the AC program to help meet his medical spenddown.
Bob is approved to receive EW services on April 18.
Action:
Bob is now eligible for SIS-EW. AC ends with EW eligibility. Bob has a waiver obligation instead of a spenddown beginning in May (the first full month of EW services).
l EW clients whose income is greater than the SIS may choose to receive services through the Alternative Care (AC) program rather than through EW, if they meet the eligibility requirements for AC.
n If clients choose AC, they may be eligible for MA with a spenddown.
Note: AC expenses can be used to meet the MA spenddown. Apply the cost of the AC services to the spenddown on the first of the month of receipt.
n If clients choose EW and have a spenddown, they:
m Cannot apply expenses paid by EW to the spenddown.
m Can apply costs incurred under EW that remain their financial responsibility to the spenddown.
Example:
Elaine currently receives AC services and is applying for MA. Her assets are within MA limits and her income if greater than the SIS.
Action:
Elaine may choose to stay on AC rather than receiving EW because her income is greater than the SIS. Her MA application is processed to determine if she can meet a medical spenddown.
The worker determines Elaine has a monthly spenddown of $1,200. She receives monthly AC services of $1,100 and pays $200 each month for prescriptions.
Action:
Elaine is eligible for MA with a monthly spenddown. Apply the AC services costs ($1,100) to Elaine’s spenddown for the first of the month, after which Elaine has a recipient amount of $100. She meets the spenddown with her prescription costs.